Six o’clock, TV hour, don’t get caught in foreign tower
Slash and burn, return, listen to yourself churn
Lock him in uniform, book burning, bloodletting
Every motive escalate, automotive incinerate
Light a candle, light a motive, step down, step down
Watch your heel crush, crush, uh oh
This means no fear, cavalier, renegade and steering clear
A tournament, a tournament, a tournament of lies
Offer me solutions, offer me alternatives and I decline
It’s the end of the world as we know it (time I had some time alone)
REM.
Note: I wrote the first draft of this about two weeks ago. It looked bad then. Since? Holy cannoli.
Sigh. Not with a bang but a whimper. This is my whimper for the month. I had other ideas for the blog. There is an acupuncture post I thought about doing. Two on chiropractic, but I suppose the one on chiropractic and the Senate is a non-starter on basic principles. I will eventually get around to them but given the rapid planned disassembly of the government, the topics seemed so trivial. Don’t get me wrong. I enjoy writing on the usual SCAM topics. So eventually.
Sports metaphors are always popular, so here is mine. Right now, if the medically oriented federal organizations such as the NIH or CDC were an NBA team, they are filling their roster and coaching staff with, well, people like me. Short, weak, uncoordinated, slow and with only a trivial understanding of the details of the games. Put that team on the court and it will not go well. Although, such a team could perhaps beat the Wizards. But I do not think the current appointments are going to be able to handle a resurgence of long controlled and mostly forgotten infectious diseases. But not forgotten by me. It was my job for 40 years to think about infections, a mindset that made me popular at parties. “Hey, did you know you could get Listeria from eating that?” and “Oh, that could be a sign of syphilis.”
My wife likes to say the best way to predict the future is to understand the past. George Santayana had it wrong. People usually remember the past, incorrectly, preferring to ignore it or figure it doesn’t apply to them. So I thought it might be fun to try and guess what is going to happen in the next decade.
I saw a few of the vaccine-preventable diseases in my long and storied career. One case of tetanus in an elderly unvaccinated SE Asian immigrant. Ever had a muscle cramp? Hurt like hell, didn’t it? Now imagine every muscle cramping at once and not stopping. Awful.
I saw one case of paralytic polio 40 years ago, again an immigrant who never received the vaccine. Lots of chickenpox over the years. A couple fatal cases in pregnancy, an awful complication, and the occasional necrotizing fasciitis complicating chickenpox, again in the unvaccinated. One case of mumps in a middle-aged unvaccinated truck driver.
I never saw a case of whooping cough, diphtheria or measles, in part because I was an adult infectious disease doctor and all the children were cared for at the pediatric hospital, and in part due to the rarity of the diseases.
Couple cases of H. influenzae b meningitis in young adults. They died. Bad disease.
I saw lots of pneumococcal disease early on in my practice and all the odd manifestations of that organism: meningitis, heart valve infections and even a couple rare cases of hemolytic uremic syndrome and Hemophagocytic lymphohistiocytosis syndrome. They died as well. But thanks to childhood vaccination, adult pneumococcal disease, along with antibiotic resistance (temporarily), went away. The importance of immunizing the vector/source of infection,
Meningococcal disease also disappeared in the second half of my practice. There is a disease that can kill and kill fast from sepsis and meningitis. Fine at breakfast, dead by dinner. Glad it was mostly gone.
Awful diseases and rare complications are, if you are a clinician and temporarily turn off the empathetic/sympathetic parts of the brain, intellectually really cool. I have said that infectious disease is kind of like birding, only interesting in that you have a life list of all the odd infections you have seen. Unlike birders, I don’t want to complete the list. I don’t want to see a case of measles or whooping cough or smallpox. I am quite satisfied with the historical descriptions. Unfortunately, the best cases with the most interesting physiology and the deepest understanding of disease are the worst for the patients. You never want to be an interesting or great case for your doctor.
What to expect? Clinicians are going to have the opportunity to see a lot of interesting, great cases. And mores the pity.
Vaccine preventable diseases will return. Measles, pertussis aka whooping cough and chickenpox will lead the charge given how communicable they are. I always remembered my specialty was infectious diseases, with emphasis on infectious. The other vaccine preventable diseases, perhaps less so. But the number of infections will be small potatoes relative to the entire US population. Vast swathes of the country will still be immune and continue to get their vaccinations. The outbreaks will be confined to communities whose vaccination rates will run in the 80%. Like Texas. More cases in red counties if COVID is any example, although anti-vaccination knows no color. There will be dozens of children who will sicken, but, fortunately, rarely die. And it will be very expensive. In 2019, across the Columbia from Portland:
The overall societal cost of the 2019 Clark County measles outbreak was approximately $3.4 million ($47,479 per case or $814 per contact). The majority of the costs (≈$2.3 million) were incurred by the public health response to the outbreak, followed by productivity losses (≈$1.0 million), and direct medical costs (≈$76,000).
But I suppose they are getting what they voted for.
I expect there will be the reports from parents whose unvaccinated children died or had horrible complications imploring people to get vaccinated. That, like COVID testimonials, will do nothing.
So I would bet against huge outbreaks of childhood diseases that will sweep the US. There will likely always be enough immunity that those diseases will fester along, causing morbidity and mortality in a relatively small population.
Huge outbreaks infecting millions will require a new pathogen where there is no preexisting immunity in the population or that has the bad combination of being both virulent and infectious, Hmm. Like bird flu could become. Look how we did with COVID when we had the best and brightest at the CDC. Moving forward?
Yeah, there were issues with CDCs response to COVID. Armchair quarterbacking is easy. I was in charge of infection control for 6 hospitals for much of my career and knowing what to do with known diseases and a small outbreak was difficult. I cannot imagine trying to control a new/unknown infection for 350,000,000 plus people. It ain’t easy and the CDC has my sympathy.
But the best and the brightest are being replaced by oh man, I don’t even have the adjectives. Starting at center, Chandra Bahadur Dangi.
And when and if there is a new pandemic, if bird flu mutates or who knows what is lurking out there decides it’s dinner time and humans are now on the menu? Man, we are so toast.
And then there is AIDS. My career started with AIDS, remembering the association is not causation. I still remember my first patient, a twenty something male, dying of disseminated M. avium, wasting away with fevers and intractable diarrhea. We did not know the cause of his disease, which made care a little anxiety provoking. I remember he told me he could spit in my mouth and not give me AIDS. Besides ick, how did he know? At autopsy he was more M. avium, than human cells. It was an awful death, the first of many I saw in the following years. Everyone in medicine probably has the diseases they don’t want to die of. AIDS, ALS, and pancreatic cancer may be my top three.
AIDS was the death no one wants. Slow, debilitating and often painful. And they could the bullet coming, Not the quick demise of a cardiac arrest we all hope for. And I saw lots of AIDS deaths before the amazing results of HAART now called ART. Much better than the Fairly Active Anti-Retroviral Therapy that preceded it. Yes, I went there. You may be young once, but you can be immature all your life. Since around 2005 I had not had a single patient die of an AIDS-related infection. Amazing.
It was nice not to give people a fatal diagnosis. One of the least fun parts of the job is telling someone they have an illness that will likely kill them in the next year or so, there is nothing to be done about it, and you have seen the effects of the disease in many of your friends. The despair and anguish of patients and their loved ones are awful. And, in the US, mostly in the past.
In Africa? About 21 million people are alive because of AIDS medications, much of it supplied and managed by US dollars gleefully being cut off.
Twenty-one million people showing up in clinics being given a death sentence. 21 million people lying in bed, staring at the ceiling, with the anguish and despair of knowing they are going to die soon and unpleasantly. Mothers and fathers and brothers and sisters and children are going to lose their loved ones. Babies will be infected in the womb and die young.
The amount of totally preventable suffering and death may be staggering.
It’s going to take time and it probably (I hope) will not happen at quite the scale of 21 million. Stop HAART and it takes a month for the HIV to rebound, 6-ish years to progress (all the while the patient is now infectious so spread increases) and kill. So some time to mitigate. But the deaths and suffering could be catastrophically huge. This one hit me hard, a pit of the stomach feeling of despair. Americans? For good or bad—well, mostly bad—we are getting what the majority voted for. Millions of those outside the US whose lives depend on us? Not so much.
As I recently heard, the willingness to inflict suffering and death is a feature, not a bug. It is a shame humans have never developed a philosophy of love your neighbor, peace and love (besides Ringo), and help the helpless. It would be nice for such a thing to exist. I dream.
The good news in all this? The death and suffering in the next century from unopposed climate change will make even this look like a walk in the cemetery. At least I will be dead.
For Whom the Bell Tolls 2025 Edition
I am an island,
Entire of myself.
You are a piece of the continent,
A part of them.
A clod to be washed away by the sea, I couldn’t care less.
I will not vaccinate.
Or wear a mask outside of a manor of thine own
Or fret of thine friend’s HAART needs.
Each man’s death? Doesn’t bother me,
For I don’t care for mankind.
Therefore, send not to know
For whom the bell tolls,
No concern of mine.
John Donne