Baffled

If you are stumbling onto this blog for the first time, some background. I was an infectious disease doctor for 36 years, retiring 3.75 years ago. Boy does time fly. I will be dead before I know it. I hope.

In that time I saw many a new infection come and stay. They seem to never come and go, just wax and wane. AIDS started around my last year of medical school (remember, association is not causation). In no particular order, there was Legionaires, C. difficile, Lyme, Ebola, Helicobacter, SARS, H1N1 influenza, MRSA and COVID. And more if I thought about it longer. Many of the infections and most of the antibiotics I used at the end of my storied career were unknown when I was a medical student.

The infections mostly had the same arc: unknown infection. No organism identified. Look for a pattern of diseases and risks to try and prevent spread.

For HIV, risks were gay, Haitian, and the use of amyl nitrate. The “joke” at the time? The most difficult aspect of an AIDS diagnosis was telling your parents you were Haitian.

Then an organism would be identified, therapies and, sometimes, a vaccine would be developed and the infection would regress a bit.

It was always a messy, bumpy, process. False starts and uncertainty are always part of the process. I learned early that when a new infection hits, those involved with investigating it have the choice of doing too little or doing too much. Public health can be a thankless job. In the end, it was usually sorted out by smart, dedicated people doing the best they could with the tools they had. Reality won. Or least there was a draw.

The biggest change over the years was the rapidity with which this arc plays out. HIV took years to be solved. COVID took months. I remain amazed at the technology that can be applied to infectious diseases. For years ID was so stone knives and bearskins: using the same agar plates from the 19th century and hope we grow something.

What changed over time, especially with COVID, were the increase in features I just do not understand.

For me, there are three kinds of understanding. One is deep, the knowledge becomes part of you. You do not have to think about it, it just is. I feel, or more accurately felt, that way about infectious diseases. Over the years my understanding became part of my DNA.

Then there is the more superficial understanding, where you have to consciously think about the topic to understand it. That was much of medicine that was not ID.

Then there are the processes I cannot understand, even intellectually. I just can’t wrap my head around the topic. Like the loop of Henle. I think it is imaginary crap, made up my nephrologists to ‘explain’ how the kidney absorbs water. Piffle.

And so much of the response to COVID I am unable to understand, the content being a Charlie Brown adult, fundamentally unintelligible noise.

As I remember COVID, and I recognize I can Maurice Chevallier this (without the creepiness), from an infectious disease/infection control perspective.

First, it was yet another respiratory infection. Been there, done that. I fretted over the first reports of H1N1 that it would be a repeat of 1918. Nope. And SARS had petered out quickly, but not before killing its discoverer. That gave me pause. So, remembering that first reports tend to lean towards the more dramatic features of a disease, I waited, half expecting it to peter out.

Then COVID started to spread. Fast. To cruise ships and Italy. Then the US. And it was a perfect shit storm. Highly infectious and zero immunity in the population. It overwhelmed NYC and Rome. Dead people stored in trucks. Horrifying. It never got that bad here in Portland.

Highly infectious and no immunity in the population is the cheeseburger and loneliness of infectious diseases. A large percentage asymptomatic but infectious. A slow course from onset to ER. And receptors for the virus in most tissues. A perfect combination for both widespread and rapid dissemination of the disease and bypassing all but the most punctilious infection control measures. Never saw the like before in my career. But all that is hindsight. In the moment there was enormous uncertainty and it took time to discover how best to deal with COVID.

As the sole, and soul, ID doctor at two hospitals, it was part of my responsibility to try to apply that uncertainty to patient care and infection control. And boy oh boy do people deal poorly with uncertainty.

Early data suggested that given my age and with my comorbidities, I had a 20% chance of dying if I got COVID. One in five. That also gave me pause going to work each day. Would not want to hold a gun to my head if there was a 1 in 5 chance of blowing my brains out. Or 1 in 1000. But I had a will and an insurance policy, so off to work.

Initially the CDC said don’t worry about masks. I will admit I took them at their word. I mean, who was I to disagree with the CDC? But if I had given it even a moment’s reflection, I would have realized that the spread was much too fast to be spread by anything but coughing.

Eventually the CDC suggested masks. I never could understand why some refused to wear masks and why those that did rarely wore the correct mask or used them appropriately:

Mask compliance among 600 individuals entering 4 New York City hospitals was observed to be 78%.

That was people entering a hospital, where they are likely on their best behavior. I bet proper use was far less in the general community from what I could tell.

Belief is what you do in the absence of data, so I never believed masks could help prevent COVID. I knew that correct PPI would protect me. It is why I could go to work every day and spend hours with COVID patients. The question was the magnitude of the effect given the issues noted above. Never did catch an infection, COVID or otherwise, from a patient nor did any staff, at least that we could tell. As best I can tell them what poo-poo various COVID preventions never had to spend time actually taking care of COVID patients or be directly responsible for the policies and procedures to mitigate the risk of their coworkers.

But I never did understand why an individual would not wear a mask, and wear it correctly. Can’t wrap my head around it. And it was red counties where people did not wear masks. And do not use condoms, so it is more than just COVID. But what is the mind set? Got me. I read their excuses but remain baffled by the content.

And I never could understand the enthusiasm for ivermectin and hydroxychloroquine. Antibiotics work by interfering with very specific metabolic pathways of pathogens. Ivermectin and hydroxychloroquine should do nothing against COVID and they didn’t. Reality holds true. I always did have an affinity for azithromycin, but due to itsanti-inflammatory effects for influenza, although the efficacy was mild at best. I never suggested it for COVID, but if the patient was on it I did not object. But why use a drug that has zero effect on the virus? Do not understand the reasoning behind it.

And then the vaccine came. Amazing new technology, subsequently abandoned. Some day we will miss not having invested in mRNA vaccines. And the people who did not mask or use condoms avoided the vaccine. And got COVID and died in greater numbers. And that approach applies to more than just COVID:.

Using individual-level medical data and death records, this study shows that conservative Americans experienced worsening health and higher mortality than liberals during the 2010s. Here we find evidence consistent with two potential mechanisms. First, demographic realignment within political coalitions brought less healthy individuals into the conservative camp. Yet by the 2020s, demographic change, public policy and COVID-19 do not fully account for the widening gap in mortality rates. Public opinion data are consistent with a second mechanism: declining trust in medical professionals among right-leaning individuals, including lower willingness to seek care, follow clinical advice or believe in medication effectiveness, even for issues unrelated to COVID-19. These patterns suggest that growing ideological divides in health behaviors are leaving conservative Americans increasingly vulnerable to preventable health risks.

I guess some people are invested in their death cult, preferring it to reality, but I will be damned if I understand why. Never go against reality when death is on the line.. But they do.

But we muddled through, with 1.2 million US deaths. Like losing two Portlands, Oregon (Portland, Oregons?). Or one Dallas, Texas. I will let you comment on which is the preferred loss. Could have been less. Perhaps a lot less.. Given the fog and uncertainty of pandemic at the time and the unique features of COVID and the political environment, probably did as well as we could. I it looks like if there is another pandemic, we are mostly primed to do far worse.

And now the same people, more or less, who championed all the approaches to COVID that increased the deaths and misery, are going after Dr. Fauchi over the origin of COVID.

because the debate about where the novel coronavirus came from is ongoing, divisive, and important.

Well, the first two, yeah. Important? Not really. Nice to know, but from a practical viewpoint, not going to prevent the next coronavirus outbreak, since we have mostly gutted the infrastructure that deals with pandemics. Common things being common, I prefer the jump from animals as the most likely source of COVID. Like SARS. Like Ebola. Like measles. Like so many others. But we will never know for sure.

One scenario, which Fauci has favored, involves a naturally occurring jump from bats to humans, probably via some other species; another postulates a lab leak, most likely from the Wuhan Institute of Virology, in the Chinese city where COVID-19 first emerged. Some of the Wuhan lab’s work involved developing new variants of coronaviruses. (Embedded in the Fauci-Paul conflict is a genuine dispute over the definition and risks of what is called “gain-of-function” research.) The institute also received funding from NIAID, via a sub-grant from a nonprofit. According to NIAID, however, the coronaviruses that were the subject of that grant were not closely related to the one that caused the pandemic.

As far as the next pandemic, if at some point we decide to prepare, we will need to consider both options.

And I cannot understand the point in publishing all of Fauci’s diary entries. They have no bearing on his work and only serve to embarrass him. The man is not perfect? Huh. Water is wet and fire is hot. What kind of person does that? No one I would want to have a beer with. The New Yorker had a summary of the diaries, and I could not see the point of its publication. I think it should be required that along with such articles, the author should submit a decade’s worth of unedited browser history. Let he who is without sin and all that.

And now the nothing burger ‘bombshell’ over concerns that the COVID vaccine might increase stillbirths (they don’t), again trumpeted by those who have no responsibility for preventing or treating COVID. I would have the occasional pregnant patient with an unusual infection that required treatment with antibiotics with little to no meaningful data in pregnancy. And we always discussed the issue. It is what Fauci did. It is what we all do. And always with the knowledge that infections are often worse in pregnancy and the understanding the much of time, there are no good options, only the least bad option.

And as an aside, I have often heard it said, in disbelief, “and RuPaul is a DOCTOR! ” Sorry. That should be Rand Paul. Unfortunately, as I do rue Paul. He has been out of medical school 40 years and a senator for 14. His practical medical understanding is likely minimal and out of date. I would estimate, from personal experience, the half-life of medical competence when not practicing is 6 months. Use it or lose it happens fast. I used to half-joke that some nurses can say the word doctor and by tone and expression for all the world you would think they were saying ignorant asshole. Doctor Paul.

So much around the reaction to COVID makes zero sense. As does the current CDC. I remain baffled that people lie and misrepresent to cause morbidity and mortality in themselves and in others. A commitment to truth and reality has always been on the losing side. Human nature. After 69 years, still can’t grok it; I continue to feel like a stranger in a strange land.

I remember when I was driving to LA for my fellowship, there was the infamous article in the ID literature, Whither Infectious Diseases? Memories, Manpower, and Money, that said there would be no need for more ID doctors and that we would end up culturing each other. Looks like we are heading the opposite direction. Lots of work coming our way with totally pointless responses. I will be damned if I understand why.