What if this is as good as it gets?

 

Many of you will recognize this as a movie quote. In the 1997 film “As Good as It Gets,” Jack Nicholson plays Melvin Udall, a neurotic, misanthropic character with obsessive-compulsive disorder. Early in the movie , he poses this question to a waiting room full of patients in his psychiatrist’s office.

This has been another week of good news. Our community numbers continue to improve. It looks as if we largely avoided a post-Labor Day surge. Texas Gov. Greg Abbott signed an executive order relaxing restrictions on certain services and businesses. It feels like it is time to reopen a bit.

But there is always a “but.” What about flu season? School reopening? Cold weather promoting viral spread by driving people indoors? Plenty of other nations (recently Israel, France, and the UK among others) seemed to have things well in hand, only to see second waves emerge and drive the return of restrictions. Why does our good news always need to be tempered with a warning to keep looking over our shoulder? What if this is as good as it gets?

The Houston regional numbers are unequivocally positive this week. Our calculated R(t) has been below 1.0 (virus is receding) for almost two weeks. New community cases dipped below 500 for the first time in months (our goal is less than 200 per day), and the Texas Department of State Health Services (DSHS) seems to be making real progress in correcting its well-publicized problems in reporting these data points in a timely and consistent manner. The test positivity rate for TMC-affiliated labs is 3.2%, well below our 5% goal (however, city and county positivity rates are running 4-5% higher than the TMC).

Although we ideally would like to see new admissions to TMC-affiliated hospitals declining, they are flat, and still 60% higher than the nadir in May; the fact they are not increasing is relatively good news. Moreover, hospital length of stay has improved to the point that more COVID-19 patients are being discharged than admitted, so hospital census of these patients continues to drift downward. We have ample hospital capacity. (If these monitoring concepts are unfamiliar to you, I recommend you review my prior messages).

Perhaps the best news of all, none of the numbers above reflect any Labor Day impact (although theoretically it still could still show up later this week). Thank you Houston: Masking, distancing, avoiding aggregating in crowds – it works. We cannot eradicate the virus, but we have shown we can slow its spread and decrease community viral prevelence.

The big news last week was a relaxation of restrictions in Texas. I would encourage you to read Governor Abbot’s executive order. In brief, Texas businesses, including restaurants, can operate at 75% of their total listed occupancy, including restaurants. Hair salons, barbershops, massage parlors and other personal care service businesses have no occupancy restrictions as long as their workstations are spaced at least six feet apart. Outdoor gatherings of more than 10 people still require approval of city or county government.

We want to avoid reliving our May reopening experience, which led to a very large June/July surge. Reasonable people may respectfully disagree on whether the new executive order goes too far, or not far enough. Thankfully, Houston still seems to be populated by mostly reasonable people. Those who believe the virus must be maximally controlled to avoid preventable death probably think it goes too far. Those who are concerned about protecting the economic livelihood of members of our community probably think it does not go far enough. On balance, the order is a logical, reasonable next step. It is not perfect, but perfect recommendations in the midst of a novel crisis are not a realistic expectation.

At the end of the day, keeping the viral prevelence low in Houston depends on most of the metroplex’s 7 million inhabitants making good daily decisions.

Last week I visited my father, whom I had not seen since the pre-COVID era. I drove back through the outer bands of Hurricane Sally, managing to skirt most of it. For the majority of the trip, the law mandated I keep my speed below 70 mph, and I set my cruise control at 76. However, when the rain came down hard, and my visibility was limited, I sensibly disengaged the cruise control and slowed down – not because this was mandated by regulation, but because I had appropriate situational awareness, and I was concerned about my safety, as well as the safety of my wife and others on the road.

So it is with our collaborative control of COVID-19 – we must maintain situational awareness to protect the health and safety of our family, friends and neighbors. I still think one of the best pieces of advice I have heard during this whole crisis came from Dr. Klotman very early in Houston’s pandemic experience: If you walk into a business/public gathering, and it feels like business as usual, turn around and walk out. It is probably not safe. Wherever people are aggregating, sincere efforts at appropriate distancing should be visible.

With Dr. Klotman’s advice in mind, as we start to relax restrictions, what are the pressure points to which you should remain alert? When do you need to take off the cruise control and slow down? A few thoughts, which reflect my opinion.

• Belief that this is “over” because the hospitals are not in danger of being overwhelmed. Gov. Abbott’s order has a safety valve built in: Reopening should not proceed if more than 15% of hospital capacity is consumed by patients with COVID-19. Currently TMC facilities are at about 6%, so we are in great shape. However, this is not the ideal metric, as it is a lagging indicator. Just like the patients with nascent heart disease who puts off preventive treatment and lifestyle changes until they experience a major heart attack, by the time our hospitals are filling up, it is too late. At that point we are already surging, and will continue to do so for weeks. A better leading indicator would be new community case numbers, but as we have discussed at length, this measure is still fraught with – improving – data reporting issues.

Tantalizingly, Baylor researchers are doing some fascinating work quantifying the presence of virus in wastewater. It appears virus in the upper respiratory tract is swallowed, and much of its antigenic material survives digestion and can be detected in human waste. If this pans out, it could provide a method to monitor a neighborhood, office building, dormitory, prison or nursing home by sampling wastewater. Preliminary data indicate we may be able to detect an increase in viral prevalence in advance of symptom development. A true leading indicator.

Advice: Do not get comfortable focusing on a signal metric – reading the speed limit signs alone is not enough.

• Settings with no capacity limits. The governor’s order allows a number of entities to operate at 100% capacity. Churches and places of worship are explicitly excluded from occupancy limits. As noted above, certain services (e.g. hair salons, barbershops) are able to function at full capacity if spaced appropriately. I am confident most (but not all) organizations will act responsibly and safely.

Advice: Ask yourself some key questions. Does this feel safe? Are others masked appropriately? Is my exposure to people outside of my household closer than six feet, and more prolonged than 15 minutes? Specific to houses of worship, keep in mind singing has been clearly established as a means of transmission, and probably results in spread of virus beyond the now famous six-foot limit. Also, avoid congregating before and after services.

• Bars. First of all, I want to stop to acknowledge the hardship the pandemic has placed on bar owners, who are mainly small, independent businesspeople trying to preserve their livelihood. Many have suffered major financial setbacks during this time, probably few more so than those running bars.

However, there is a reason bars have largely been closed. Congregating a high density of people in a contained indoor environment for extended periods of time with inconsistent mask usage is a perfect set up for viral spread. Add a little alcohol-induced social disinhibition, and viral spread is highly likely. Some establishments have creatively leveraged their food services to allow for table service (by order, at least 51% of sales must be attributable to food). But regardless of whether it is a “bar” or “restaurant,” a crowded indoor space is a crowded indoor space.

Advice: Ask Dr. Klotman’s question. Does this feel like business as usual? If the answer is yes – if there is not real evidence of compliance with good distancing practice – it is probably not safe.

So is this as good as it gets? Perhaps, but that is not necessarily a bad thing. Nicholson’s Melvin Udall was not “cured” of his neuroses, but he found meaning in human connection. We can continue to reclaim our lives, cautiously expand our economic activity, return to school, etc., if we all band together, maintain situational awareness and continue doing what we have proven works: Mask, distance, be wary of crowds – a reasonable price to pay to resume our lives while protecting each other.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

 

 

Safely Reopening Schools

It feels to me like we are approaching some sort of inflection point. Our hospitals appear to be out of danger of being overwhelmed. State leadership is signaling plans to begin to relax some restrictions, and local leadership made some cautious and preliminary steps in that direction as well. HISD has started virtual school, and is about a month away from resuming face-to-face instruction. We are making halting, careful steps to safely reclaim more of our pre-COVID-19 lives. Leaders are struggling to make responsible decisions, while continually – and very appropriately – chanting our new mantra: mask and distance, mask and distance.

Last week I reflected on balancing our pride in all we have collectively accomplished in this battle against SARS-CoV-19, with what should be a sense of humility driven by what we do not know. That theme becomes even more important as we start to make decisions to relax various restrictions. Done thoughtfully, we promote the well being of our children and encourage the economic health of those who have been impacted by the viral-induced slow-down. Done poorly, we will promote another surge, and with it significant health consequences.

Starting with the positive, the Texas Medical Center (TMC) data continues to improve. The number of new patients admitted to TMC facilities continues to trend downward, and is approaching levels seen in April and May. With fewer admissions, as existing patients are discharged (or unfortunately, expire), the census in TMC affiliated hospitals is falling. We are still a week or so away from seeing what kind of Labor Day impact we might experience, but so far, so good. This is unequivocal positive news, based on solid numbers.

The new community cases is a different story – good news in that the trend is in the right direction, but concerning in we are not entirely confident in the data. Over a month ago, we started to notice some inconsistencies in the case rates. The data from the Texas Department of State Health Services (DSHS) reflected an increase in the number of people being tested, but all of our local labs – Baylor included – were seeing a decrease in testing volume.

It has now been well documented this disconnect had a good explanation. DSHS found itself responsible for an unprecedented demand to receive, organize and report testing data from hundreds of labs across the state. This was a task for which it appears they were ill equipped to manage, falling far behind in accurately assigning testing results to individual counties and municipalities. Since that time, they have upgraded technology, and are playing catch-up entering a backlog of test results. This week DSHS announced a significant overhaul of processes, data quality assurance and reporting formatting which should produce more reliable results.

As a result of DSHS data issues, when we look at the reported new cases today, the numbers include cases from June, July and August, or even earlier. The unfortunate consequence is our current new cases are probably being overstated – we are doing better than we think. Also, in retrospect, because cases were not being entered in June and July, we were in even worse shape then than we knew.

At some level, this is not as bad as it might be. We are probably doing better than we think today. We already survived June and July when the numbers were understated. However, at this inflection point, it is disturbing we do not have confidence in a major benchmark. We are trekking through the wilderness with a broken compass. We are flying a plane in poor visibility conditions with an unreliable altimeter. Are we at 5,000 feet or 500 feet? I am not a pilot, but it seems to me some precision in this metric is important, as our new case rate number will be as we make decisions to reopen schools and relax other restrictions. Again, hopefully with the DSHS changes, this problem is behind us.

So now we are contemplating the reopening of face-to-face schools, armed with incomplete and evolving information. Decision-making is relatively easy when you have all the facts. Critical decisions are much more difficult based upon incomplete or conflicting information. This is the unfortunate position in which we find ourselves. State and local governments, local school boards, and – most significantly – millions of parents are struggling to make the best decision for children across the nation. Most are showing an appropriate level of caution.

In closing, I would like to offer a few thoughts on what communities, schools and parents can do to maximize success of school reentry, and recommend some specific resources.

What can communities do?

• Mask and distance. Continue to push good viral control practices in the entire community – not just among students, teachers and parents. SARS-CoV-2 is every bit as infectious as it ever was. We are nowhere close to achieving herd immunity, either through spread of infection or vaccination. Masking and maintaining appropriate distancing (6 feet or more) is inconvenient, but a small price to pay to get our children back to school.
• Do not resume full face-to-face school until your community has a sustained low rate of disease. The new community cases should be steady – or ideally declining. New cases should be at a low enough level so health departments can realistically perform contact tracing. In Harris County, that is about 200 cases/day (we are currently at 744 per the county website). If you live in communities outside of Harris County, the consensus number seems to be somewhere between 2-8 cases per 100,000 population.

Controlling the disease through contact tracing is like rowing a leaky rowboat. If the boat has a slow leak (low disease incidence) you can bail out some water every few minutes, keep rowing and be safe. On the other hand, if the boat has a gaping hole in the hull, you can bail as fast as you can, but you are going to sink. If we are in a high prevalence environment, SARS-CoV-2 will overwhelm even the best-designed defenses, and outstrip the ability to perform contact tracing. We cannot put our children in a sinking boat.

The current lack of confidence in DSHS data – hopefully resolved – make this more difficult, but the uncertainty demands we proceed cautiously.

What can schools and school boards do?

• Refer to Baylor College of Medicine's "Guide to Reopening Schools." Baylor developed a guide to help walk school leaders through critical questions. Where will masking and distancing tend to break down? (bathrooms, cafeterias, entrances, buses). What issues are important to assess in a school's physical plant? (air flow; water systems). How do I keep teachers safe? (cloth masks and face shields). How do I manage symptomatic or exposed students and employees, and when is it safe to bring them back?
• Establish teacher/employee monitored e-mail address for COVID-19 questions and concerns. Even with the best policies and training, there will be many specific questions that arise. Establish a dedicated email address to receive these questions, and commit to a timely response. Ideally, engage an objective, third party expert panel to assist with the subset of more complex issues and novel problems. The availability of rapid and reliable answers to teacher and employee questions will help to quell the inevitable anxiety that many will experience as schools reopen.

What can parents do?

• Get involved. Like many other components of the educational process, active involvement of parents in their children's schools will drive better outcomes. Pay attention to communication from your school. Is there a well-articulated plan for returning to the classroom? Does it seem thoughtful and comprehensive? Is communication frequent and transparent? Based on the experience to date with colleges and universities, the re-entry process will usually go well, but some schools have challenges. Frequent and open communication between parents and school leadership will be key.
• Get educated. That is, learn the basics about COVID-19, so you can begin to separate fact from fiction and opinion. Baylor provides a free online resource that is actually geared towards K-8 science teachers. However, it also a good source of unbiased, factual and accessible COVID-19 information.
• Assess your child's unique situation. This pandemic is forcing parents to make hard decisions. Does my child learn well on-line, or do they need the face-to-face structure of the classroom? Is my home even equipped to provide a good on-line learning environment? What is impact of home-based learning on my child's social and emotional well-being? If schools are not open, how can I return to work? Parents of children with special needs will have even more complexity to work through. Involved parents who understand the unique needs of their children are really the only ones in a position to answer these questions, and strike the right balance for their child. The CDC developed a good self-assessment checklist to help guide parents, caregivers and guardians through this process.

So as we move towards in-person instruction, let's draw on lessons from our COVID-19 past. We have proven we can do the hard work of engaging entire communities to band together to control the virus. Our knowledge continues to rapidly expand. We should be humbled by a clear-eyed recognition of what we do not know, but that humility should not lead to paralysis and inaction. We can and will pull together to get our children back to school, thoughtfully and safely.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Pride and Humility

 

It is hard to believe that we have been living our COVID-19 lives only since about last March.  It has been a shade over six months, but it seems so much longer than that.  As I pause to reflect on our shared journey over that time, the first two words that come to mind are “pride” and “humility.”  I mean pride in the positive sense: that which is earned and justified.  Humility reflects how far we yet have to go.
 
But first, the recent numbers.  There is little drama here this week, and let us all hope it stays that way.  Most of the national and state numbers are improving.  Regarding our Houston regional specific numbers, please refer to prior posts for a more complete explanation of the key TMC metrics. In short, our R(t) value (the estimate of viral infectivity) is down below 1.0 again, which is good.  New case rates in Harris and surrounding counties are slowly drifting down, albeit more slowly than anyone would like.  Recall, we want this number to be less than 200, about one fifth of its current level.   These two data points demand a word of caution:  The R(t) and new case numbers are not independent variables, and both are impacted by data reporting issues from the state.  I do not yet have confidence in the validity of these two metrics.  The reporting backlog seems to be improving, but there are still open questions as to when a new case is added into the state’s database (Date of specimen collection? Date of data entry?), and how duplicate entries are managed.
 
The TMC’s third monitoring metric – test positivity percentage – currently sits at goal at 5 percent and this is a reliable number as it is based on data directly flowing from TMC institutions.  Harris County’s positivity rate is also trending down, currently at 9.5 percent.  Test positivity rate is a very rough estimate of disease incidence in the community.  In order to reopen schools and relax other restrictions, we need to have a low disease incidence (rate of appearance of new disease) and prevalence (total amount of disease in the community at any given time).  
 
For the past couple of weeks, I have started to focus on the TMC new COVID-19 hospitalizations.  From a high of about 360 admissions per day in early July, this dropped to 88 per day two weeks ago, but inched up again last week.  It now appears to be trending back down again.  Keep your eye on this number if you are looking for a “Labor Day” effect.  Recall, viral exposure leads to a sequence of events. The virus incubates in the respiratory tract.  In at least some people it produces disease severe enough to require hospitalization.  This process from exposure to hospitalization takes on average 7-14 days.   I will be very curious to see what the new hospitalizations are on Sept. 21, and if they are rising or falling.  I predict they will be higher.  Fourteen days after Memorial Day, we saw an increase in new community cases of about 65 percent (from 285/day to 470/day), and they kept on growing from there.  New hospitalizations were not far behind.  Two weeks after July 4th, new cases increased by an almost identical percentage (64 percent from 1400/day to 2300/day). 
 
In retrospect, things started to improve from mid-July forward.  It is a shame we cannot rely on the new community cases data, as this is probably our best canary in our coronavirus coal mine, but watch the new hospitalizations.  If they are trending up, we could be headed for another disease surge.  Perhaps – hopefully – enough people have embraced masking, distancing and safe practices at this point that it will dampen the Labor Day impact.
 
All projections are dicey.  Like trying to predict if Hurricane Laura will hit Houston, there is no simple model, and things can change quickly.  We all crave certainty, which no one can offer at this point.  Which brings me back to the theme of humility. But first, pride.
 
If you step back and reflect on the expansion of SARS-CoV-2 (the pathogen) and COVID-19 (the disease) related knowledge over the past 6 months, it is stunning – almost explosive.  In very rapid fashion, we – scientists and clinicians – have learned a ton about the basic genetics, lifecycle, evolution and structure of the disease.  The cellular binding receptors have been identified, and we have some understanding of the human body’s complex and variable response to infection.  We have a well-defined understanding of the course of the disease, and we have developed partially effective treatment protocols and novel drug therapies.  We are well down the path of developing multiple vaccines, while systematically assessing their safety and efficacy.  We are beginning to understand the long-term complications of the disease.  And – notably – we have accomplished this while keeping providers safe.  For all our failings, and recognizing many things could have gone better, we should be proud.  Our research and care delivery system performed admirably.
 
However, there is a consequence to this rapid growth of knowledge.  Dr. Charles Burwell, a former dean of the Harvard Medical School, in an address famously told a class of new medical students, “half of what we are going to teach you is wrong, and half is right.  Our problem is that we don’t know which half is which.”  So it goes with COVID-19 knowledge.  What we think we know today may prove wrong tomorrow.  Treatments that seem promising in case reports, case series and meta-analyses fail to demonstrate benefits in randomized controlled trials.  New basic science discoveries will drive the development of treatments not yet contemplated.  This is not a flaw in our system – it is our system working as intended and working very well.  
 
Now, humility.  SARS-CoV-2 has humbled us along the way.  As we contemplate returning children to face-to-face classrooms, one great example of how our knowledge has evolved relates to how the virus impacts children.  In the few months we have been battling this pathogen, the thinking on involvement in children has changed dramatically.  
 
When COVID-19 first appeared on the scene, the common thinking was that children were not really susceptible to infection.  They rarely contracted the disease, and if they did, it was usually mild.   
 
Very shortly thereafter, it was discovered children with COVID-19, as a delayed complication, may develop a condition resembling Kawasaki’s Disease, a rare disease of unknown etiology that results in diffuse inflammation throughout the body and is a significant cause of acquired heart disease in children.  Although still rare, COVID-19 could no longer be considered an entirely benign pediatric condition.  
 
Weeks later, the thinking evolved.  Children were contracting COVID-19, and being hospitalized, with the most severe cases unfortunately rivaling the adult experience.  However, the severe cases seemed to be mainly confined to obese adolescents.  
 
More recently, data from a sleepover camp in Georgia showed COVID-19 spreads with surprising ease among children of all ages (campers were aged six and above).
 
Finally, today.  It is clear children do contract COVID-19. The American Academy of Pediatrics summary of state reporting data on children clearly indicates children become infected with the virus (over 476,000 cases to date, almost 10 percent of the total number of documented infections).  However, thankfully, hospitalizations and death are uncommon.  The risk of spread from asymptomatic children to adults remains unsettled.
 
Now as we contemplate returning tens of millions of children to school  – an educational, emotional, social and economic imperative – think about the above evolution and how reasonable recommendations may have changed from then to now, based on what we thought we knew.  Early on, it might have been rational to reopen schools with minimal precautions.  Based on current knowledge, we need to plan cautiously, with adequate protection for children, teachers and staff.  We also must consider and manage the risk to vulnerable adults living with school age children.
 
There are other examples of how knowledge has evolved.  From “don’t wear surgical masks, we need to save them for health care workers and first responders” to “everyone should be wearing a cloth mask.”  We used to think transmission from inanimate objects was a significant risk.  It is now clear this is not a major mode of transmission (you should still wash your hands regularly, and keep them away from your face).  I will repeat.  The evolution of evidenced-based guidelines is not a flaw in our system – it is our system working as intended.
 
We need to balance these two sides of our coin: pride and humility.  By embracing both, other virtues follow.  We will have the confidence to move forward, making timely decisions with incomplete information.  We will have the maturity to change our practices and behaviors as new evidence emerges.  Importantly, we will display charity and patience with leaders in our civic, medical, educational and business communities who are acting in good faith to protect people and mitigate the impact of this novel global disaster.
 
Stay well.

James T. McDeavitt, M.D
 
(Here is a link to today’s message: https://bit.ly/32fT2hT. Please feel free to share and post)

 

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

The Wisdom of the Crowd

 

I am not going to write a weather-related piece today, as everyone is likely receiving plenty of information through the usual sources.  As I write this, it is mid-day Wednesday and it the path of Hurricane Laura is becoming more certain.  It appears it will not hit Houston directly, which if forecasts hold would help to mitigate the impact.  However, many are still directly in the path of a very dangerous storm, and our thoughts and/or prayers are with them.  Our support will be needed in the aftermath.

 
Obviously, there is concern about what impact this event could have on our COVID-19 outbreak.  If large numbers of people are displaced, and forced into congregate shelters, this will create a risk of spread of COVID-19.  Public officials have taken steps to limit the size of shelters and incorporate distancing principles into their design and operation, but any significant population displacement will place additional pressure on disease control efforts.
 
So with that brief nod to the issue that is on everyone’s minds today, I will return to an update on COVID-19 issues.  A couple of weeks ago, I posed the question to all of you: “If you were advising one of our presidential candidates, or local leadership, or a company executive on preparation for the next global pandemic, what is your priority?”  You emailed your responses to me, or posted them on Twitter using the hashtag #TheNextPandemicBCM where they are still available for review.  Following a brief review of our COVID-19 numbers, I want to report what you said.
 
The COVID-19 numbers continue to trend well, for the most part.  From prior posts, you know we are focused on three primary metrics: R(t), diagnostic test positivity rates among TMC facilities, and the number of new daily COVID-19 cases in Harris and surrounding counties.  
 
Recall the R(t) calculation is an estimate of viral infectivity, influenced by the properties of the virus and community dynamics.  Simply put, if I am infected with COVID-19, the R(t) is a statistical estimate of how many other people I am likely to infect.  If R(t) is less than 1.0, Houston is winning; greater than 1.0, SARS-CoV-2 is winning.
 
Even with a highly infectious virus (like measles), if we are truly and completely isolated from everyone else – a condition which only exists as a hypothetical – the R(t) would be effectively zero.  Conversely, if we all tend to congregate in crowded spaces with poor air exchange for prolonged periods of time, even a virus which is not inherently very infectious could have a very high R(t).  This is why attention to masking and distancing is so important.  The good news this week is the R(t) has been consistently less than 1.0 for 16 consecutive days.  As of now, we are winning.
 
Our second metric is the rate of positive tests among all tests ordered by Baylor and other TMC affiliate institutions.  This is a rough gauge of viral prevalence, which we would like to see sustainably below 5%.  The TMC positive test percentage is now 6.7%, and has been slowly trending downward.  This is not where it needs to be, but is headed in the right direction.  If you follow the city, county and state numbers, you will note that their percentage positive tends to be a few points higher.  This probably reflects some selection bias on the part of the Baylor and TMC facilities cohort.  Although we test symptomatic people in our ambulatory clinics, much of our testing is asymptomatic employees in surveillance programs, and asymptomatic patients admitted to hospitals, who would be expected to have a low positivity rate.  
 
However, we are very confident in the integrity of the data point we generate, which is why we have chosen this as our metric.
 
Finally, our most problematic metric: new daily COVID-19 cases in the community.  This number is (very) slowly drifting down, and on a 7-day rolling average basis is between 1,400 and 1,500.  This is good news is that in mid-July we were at about 2,400 cases.  However, we are still seeing 5-6 times the number of daily cases compared to May, and for public health officials to have a realistic chance of performing effective contact tracing it needs to be closer to 200.  This metric is the most methodologically flawed, for reasons I have previously reviewed, but should be increasingly reliable as state data issues are resolved.
 
In summary, the trends are encouraging, and hopefully future community stressors like school reopenings, the Labor Day holiday, flu season, etc. will not set us back.
 
Please continue to preach the masking and distancing message to your circles of influence.  
 
I hope we as a nation will get to a point soon – we are not even close yet – where we can stop managing the crisis in front of us, and begin to focus on how to be better prepared for the next pandemic.  That was the point of the five word #TheNextPandemicBCM exercise.  Roughly 100 people from the broad Baylor community responded.  Some people responded with tactical concerns, such as the need to stockpile PPE. A few made – mostly respectful – statements favoring one side of the political spectrum or the other.  Most responses addressed broad, fundamental key principles.  Taken individually, none of the principles is particularly surprising; however, there were four major themes when taken together constitute a thoughtful outline for how we can be better prepared next time – the BCM crowd-sourced pandemic preparedness plan:

• Elevate the role of rigorous science in public policy.  Example of five words: Build public confidence in science; Clear communication improves scientific understanding; Trust scientists and not Facebook.  Fully one quarter of respondents reflected this theme in some way.  
• Build reliable data and reporting systems.  Five words:  Worldwide electronic medical interconnectivity; Good data drives good decisions; Reliable information must unite us.  
• Invest in public health infrastructure and education.  Your words: Comprehensive integrated public health network; public health in high school; Public health investment dollar well spent (technically, this last one is six words, but it was too good not to include)
• Effective leadership is critical. Effective leadership: national, regional, local; Good leadership drives action; Clear messaging from leadership unites.

Our limited “Twitter poll” is obviously not a methodologically sound, comprehensive analysis of our current state nor an attempt at meaningful future planning.  However, the Baylor community does represent an interesting collection of researchers, educators, clinicians and learners.  Our exercise does represent a limited snapshot of the mood of this community at a time we were still actively engaged in our struggle with the virus.  Based on this snapshot, we should be advocating for public health curricula across the entire educational landscape: elementary to graduate school.  Our more informed populace will need reliable data presented in an accessible manner.  Our scientific community will continue its long-established commitment to academic integrity.  Leaders need to be able to promote an environment of trust and confidence.  These concepts may seem so obvious as to be trite.  However, if we do not actively work to address these – and no doubt other – issues now, our motivation and sense of urgency will flag as COVID-19 fades into memory.  As a learning health system, we have an obligation to hold our societal feet to the fire.
 
Stay well and stay safe.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

D-Day

This week’s message may be slightly longer than usual, but I hope you will read it to the end.  As the viral dynamics continue to improve in and around Houston, I want to pause to recognize a group that has borne a disproportionate brunt of pandemic-induced pain – our front-line health care providers (HCPs). Theirs is a compelling story.

 
Before I proceed, I will very briefly mention this week’s data.  Our “R(t)” value is less than one (so we are winning).  Hospital COVID-19 related census levels continue to drop steadily.  The rate of new community cases is declining, albeit more slowly than anyone would like.  The percentage of people with positive tests is declining.  This is all favorable news.  If you are not familiar with some of these terms or concepts, please refer to last week’s message for more details.
 
Things are looking up, but I must revisit a persistent theme in these messages:  We must remain vigilant; we cannot become complacent.  Mask, distance, and avoid crowds.  Settle in for the long haul because we will need to live cautiously for months if we are going to be able to open up schools and maintain something that approximates our pre-COVID life.  Again, refer to last week’s message for more details.
 
Now, on to front-line HCPs.
 
Every one of us has suffered, to varying degrees, during this pandemic.  I have two new granddaughters, one born in September, and the other in June.  I consider them both pandemic babies, born in a strange time.  My younger granddaughter is named after her great-great aunt, who was an Army nurse, and part of the mobile medical response team that landed with the D-Day invasion in World War II.  She has since passed away, but in all the years I knew her, I never heard her talk of her experience.  I suspect it was horrific.  Everyone in the United States suffered during WWII.  There was fear of a mainland invasion, rationing of food, coffee and fuel, and shortages of rubber directed to the war effort.  However, given that during D-Day almost 3,000 Americans died, and four times that number were wounded, most would agree that the suffering of the many back home did not compare with the experience of those who stormed the beaches.
 
Have I suffered during the pandemic?  The honest answer is “yes, but…”  
 
Yes.  I have worked a little harder than normal.  In welcoming our pandemic babies to the family, we have cancelled baby showers and missed a large family gathering for a baptism.  We have not been able to jump on a plane for a quick visit.  Everything is a little more complicated, and a little less convenient.  To be sure, we feel fortunate that we have not suffered loss of livelihood, or health, or life – as many have.  
 
So we have suffered, but not to the extent of our front-line HCPs.  In this SARS-COV-2 war, they are the soldiers, and our ICUs are the beaches of Normandy.
 
In preparation for this piece, I spoke to about a dozen inpatient front-line HCPs in several Baylor affiliates: Baylor St Luke’s Medical Center, Ben Taub Hospital, and Texas Children’s hospital.  I spoke to intensivists and hospitalists; nurses and residents.  I wish I could have spoken to them all, as they all had an important story to tell.  What follows are a few of my questions to them.  The responses are their words, not mine.
 
We have been dealing with this crisis now for six months.  Tell me about your hardest day during that time, and what made it hard?

• My hardest day was when I worked my first shift in a newly-designated “all-COVID” unit.  All the patients were incredibly sick.  There were multiple codes.  I couldn’t leave one patient’s bedside long enough to attend to the next one.  I went home and cried.  I had to let it out.  It was one of the worse days of my life.
• Watching a young patient deteriorate before my eyes; seeing families devastated by the disease affecting multiple people.
• We are a people called to care.  In the early days, there was nothing we could do that seemed to help.  It is hard when you can’t see a path forward.
• I always try and take care of my people.  I couldn’t help them.
• I was worried about my family – that they would contract the disease.
• It was physically grueling work.  At any given time, 70% of our ICU patients were on a proning protocol.
• It is very hard to take care of sick kids when both parents can’t visit, they can’t see my face though my mask, and I can’t sit on the edge of the bed.

What single word best describes your feeling on that day? 

• Draining (multiple responses)
• Helplessness
• Overwhelmed
• Numb
• Anger (at the lack of resources in the early days, at the community at large for not taking this seriously)
• Despair

What did your team of health care providers do well?

• We had a shared spirit, and collaborated broadly.  It was one of the most rewarding experiences of my life.
• I was proud of our new faculty.  They were fearless.
• Everyone was committed.  Everyone sacrificed family responsibilities, vacation time.  We all worked long hours.
• We really rose to support each other. I was incredibly impressed and proud. Teamwork.
• We adapted rapidly, and learned quickly.  We became masters of data-driven micro-innovation.  We are better for this experience.
• Even though everyone was already incredibly busy, we held frequent Zoom meetings with regional hospitals to review cases and treatment protocols.  We felt an obligation to help build capacity and improve quality across the region, just not in our hospital.

Imagine a time when COVID-19 is truly behind us.  What is the single biggest lesson we should have learned from this experience?

• Our health care community is incredibly valuable.
• I cannot function without a great team around me.  I have an overwhelming sense of humility, and gratitude for my colleagues.
• We need to be ready next time. 
• Stockpile PPE.
• Enhance our public health systems – earlier control, more effective contact tracing.
• We have a leadership responsibility for the region.
• Life is precious, but uncertain and fragile.
• Putting others first is the best way to take care of yourself.

I hope we learn these lessons.  I hope our front-line health care providers differ from the survivors of the Normandy invasion in one important way – I hope we continue to talk about these experiences.  Experiences that have been incredibly hard, but at the same time affirming and formative.  As one person commented, “talking about this has been very therapeutic.”
 
In closing, I want to express my admiration and gratitude to everyone in our professional community who has been on the front lines sacrificing to provide extraordinary care in extraordinary times to our families, friends and neighbors.  May we never forget.
 
What would you like to communicate to a front-line health care provider?  Using exactly five words, post to Twitter using the hashtag #COVIDThanksBCM, or send your five words to svpclinical@bcm.edu, and I will post some of your responses.  Also, as many have asked, feel free to share this message broadly. You can copy and paste this link to email messages or social media: https://bit.ly/3277mrt.

So what are your five words of thanks?  I will start, with apologies to Winston Churchill:
 
This was their finest hour.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Better Living Through Our Shared COVID Experience

Habits.

In general, it takes about three months of regular performance of a new behavior to develop a habit – to incorporate actions into your life that becomes largely unconscious and effortless, like brushing your teeth. In my mind, the crisis in Houston became real with the closure of the Houston Rodeo on March 11. Since that date, we have all been dealing with change on an unprecedented scale. Work changed, the economy slowed, schools closed, we experienced two disease surges (or as some would contend, one long continual surge). Using the Rodeo as a marker, we are now in our 5th month of the crisis – plenty of time to have developed new habits. Today I would like to briefly review the improving data from the past week, while pausing to contemplate what positive lessons we have learned so far. How are we going to be better for having lived through this historic crisis?

We are clearly in a transitional period. The numbers this week are encouraging. For the past two weeks, the R(t) – the measure of community viral infectivity – has been at or below 1.0 due to community masking and distancing efforts. It now appears we achieved our peak of new viral infections during the 2nd week of July. New community cases in Harris and eight surrounding counties, on a rolling average basis, have decreased from about 2,400 daily at peak to around 1,800 (but keep in mind, for most of April and May we were seeing fewer than 400 cases per day, so we are still seeing a lot of new disease). New community cases reflect all positive tests, including people who are asymptomatic or minimally symptomatic.

The decrease in community disease burden in showing up in slackening hospital demand. Across TMC institutions at peak, daily admissions were above 350; we are now below 250. The daily census of patients in non-critical medical/surgical beds is dropping, and ICU patient census – which is expected to lag these other indicators – is starting to drop. In short, all the metrics are headed in the right direction.

To be clear, this does not mean things are easy. Providers in hospitals are still managing high numbers of very sick patients. Faculty, providers and residents in ICUs are fatigued. All tertiary/quaternary hospitals are providing extracorporeal membrane oxygenation (ECMO) to record numbers of patients. There are parts of Texas, particularly in the Rio Grande Valley, that are still squarely in crisis mode. So again, this is not over – just better. Vigilance around masking and physical distancing must continue. When the time is right, we must continue to encourage thoughtful, data-driven reopening decisions.

So, as we ride the backside of the current wave, I would like to reflect briefly on lessons learned – societal, organizational and personal. What new habits, skills and strengths have we developed during this crisis?
On the broadest societal level, I think this is a difficult question to answer. This will no doubt be the subject of many books to come. One lesson learned should be that the U.S. deserves a less fragmented, better-coordinated public health system. I hope this is my only global pandemic, but if we are ever unfortunate enough to experience something like this again, as a nation we must be better prepared.

In terms of institutional lessons, we have had a glimpse of what it means to be a learning health system. The AHRQ describes an learning health system as a system where “internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.”

I think that summarizes our last five months remarkably well. We have proven that if we have focus and organizational commitment, we can do big things quickly and do them well to improve the health and well-being of our community. The Baylor collection site just “swabbed” patient 10,000 this week. While other labs are challenged to provide timely results, Baylor labs continue to provide region-leading turnaround time for high reliability testing. Our researchers continue to manage productive labs and submit COVID and non-COVID related grants. Telehealth services enable us to provide necessary services to patients, and in a challenging environment, we are ahead of pace to recover all of our pre-COVID patient volume. Psychiatry in particular is performing the majority of their services virtually – including direct services in support of many in the Baylor community – and are on pace to exceed their pre-COVID levels of patient care. Curricula have been redesigned, and new students, residents and fellows smoothly onboarded. I hope a residual Baylor habit is recognizing we can accomplish important things quickly and well.

On a personal level, all of our lives are different than they were. We have faced a ton of disruption and much negative and difficult change. I think it is useful to stop and reflect for a moment on what is better, however small those things might be. What new routines have we established that we find meaningful and valuable? How would you finish this sentence?  “In the post-pandemic world, I will continue to…” These habits can be small or large, but pause to think about what they might be. For me personally, two come to mind. In the post-pandemic world, I will continue to…

• Limit my professional travel. Like most of you, I have not been on a plane since February, and have discovered I really do not miss it. I have more time at home, and seem to have been able to fulfill professional obligations fairly well remotely. To be sure, when travel becomes routine again, some face-to-face interactions will and should resume. However, I like being at home with my family and will be more selective about future trips.
• Have Sunday lunch with family. We have a new tradition of sitting down to mid-day Sunday for a family meal (within our household). Although we typically do take-out rather than cook, this feels like a throwback to a less hurried era. Pre-COVID-19, we had limited opportunity for unstructured, leisurely conversation; somehow now it seems to be more important.

In the post-COVID world, what positive thing will you continue to do? Take time to reflect. If you are inclined to share, email me your (brief) sentence, or if you are on Twitter, post using the hashtag #COVIDHabitsBCM.

Stay well.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

A Cautionary Tale

My message today is a little different.  Generally, my comments are directed to the Baylor Community, and I hope they may have broader applicability.  Today’s message is squarely directed outside of Baylor.  Please share it widely, and share it today.

You do not need me to tell you the SARS-CoV-2 situation has substantially worsened over the past week – every media outlet in the nation is covering that story.  We are in the midst of a major surge.  Our affiliate hospitals are working hard to make sure there will be beds available to meet the demand, staffed by qualified healthcare providers.  We are prepared, but clearly are in for a challenging couple of weeks.  As we manage increasing volumes of patients, and especially as we enter the holiday weekend, the most important thing we can do is work to slow the spread of COVID-19.  That is why I think the story of Frank and his family is so important.

Note: I changed the name of the main person in this story to Frank Wilson and left out some details, not at his request, but to allow this story to be told without intruding on the privacy of anyone involved in this story. The story is real, the people are real, the impact on their lives is real.

Frank Wilson and his extended family have lived in the same town for more than 40 years – three generations.  They are a close-knit family in a close-knit community.  They enjoy a pace of life that is at least a half step slower than a city like Houston.  This is the story of SARS-CoV-2 in a place far removed from the intensity and complexity of the Texas Medical Center.  It is a story of good people in a safe place.

The Wilsons planned to spend their Memorial Day the way they spend most holidays and many weekends – enjoying a family gathering at their favorite picnic spot.  This celebration took on a little more significance, as they were coming out of the coronavirus induced lock-down.  As regional leaders mandated a partial shutdown of the economy, they suffered along with the rest of the state and the country – lost shifts at work, cancelled family events.  Now public officials were reopening the economy, and life was trying to regain its normal rhythm.  There was nothing more normal for Frank than a family picnic.

What did he think of all the coronavirus warnings?  “I thought it was all a big hoax – the government trying to take control of things”.  He knew people in other parts of the country had the virus, but he did not personally know anyone who had it.  He didn’t even know anyone who knew anyone who had it.  The response of media and civic leaders seemed overblown.  “It was a big nothing.”  Thankfully, it seemed now it was behind us.  We were opening back up.  We had beaten the virus.

This Memorial Day was like countless other similar holidays – an opportunity to unwind and relax with family.  It would become a day – that would lead to a week – that would change their lives forever.

The first warning sign.  Frank’s mother became short of breath.  Her symptoms were severe enough they felt compelled to get her checked at a local emergency room.  She was evaluated and told that she was suffering from a “broken heart.”  She was still mourning the recent death of her husband – Frank’s father – and it seemed reasonable that her symptoms were anxiety related.  All were relieved it was not the virus.

Memorial Day was Monday, May 25.  Tuesday passed and was uneventful.  

Wednesday, Frank went to help a friend tune up the engine of his car.  Towards the end of the day he didn’t feel well.  That night his temperature went up and he called his boss to say he would not be at work.  He went to the hospital and got the COVID-19 test.  Results the next day – positive.  He had the virus.

Thursday, Frank’s wife developed similar symptoms.  She went to the hospital, and was sick enough to be admitted.

Also on Thursday, Frank’s mother-in-law became ill.  In retrospect, she had not felt right since mid-May, but had already had a negative test for COVID-19.  She went to the hospital, and was admitted.

Friday, Frank’s sister became ill. Like his wife, she went to the hospital and was admitted.

By Friday evening, his mother’s condition had worsened to the point he sat at her bedside all night.  He did not realize it at the time, but this would prove to be the last night she would spend in her home.  On Saturday, he took her to the hospital, and she was admitted.

Thus ended a week from which the family is still struggling to recover.

Frank was lucky.  He did not need to spend time in the hospital.  However, he tells me it was the worst thing he has ever had.  “It was ten times worse than the worst flu.  I had terrible stomach pain, and couldn’t get my breath.  It felt like a bomb was going off in my chest.”

His wife’s condition was severe enough that it looked like she would need to go on a ventilator.  Fortunately, with a combination of regular proning (face-down positioning that improves air exchange in COVID-19 patients) and high levels of supplemental oxygen, she avoided the ventilator and was discharged after about a week.

His mother-in-law’s condition deteriorated, resulting in a prolonged ICU stay.  She is profoundly weak and continues to undergo intensive rehabilitation.

Frank’s sister also wound up in the ICU, and required extracorporeal membrane oxygenation (ECMO).  This is used in patients whose lungs are so badly involved that they cannot effectively exchange oxygen between the airways of the lungs and blood, which is much like slowly drowning.  The patient’s blood is drained out of the body, infused with oxygen and replaced.  Thankfully, she recently improved to the point that she is off ECMO, although she remains hospitalized.

Frank’s mother was the most critical of all.  She was admitted to the ICU and received the best and most aggressive treatment possible, at the finest medical center in the world.  She participated in the convalescent serum trial, receiving antibodies from another patient who had recovered from COVID-19.  Despite heroic efforts, she passed away. 

This is a true story, as told to me by Frank – real people, real events. After seeing the devastation the virus brought to people he loves, his instinct is to do all he can to help others.  He wants to donate his plasma so someone might benefit from his antibodies.  Most importantly, he wants people to know the threat is real, and that everyone must act responsibly to protect each other – to protect people like his wife and sister and mother.

Our most important weapon to control the viral invader is our own safe behavior.  Mask when in public places and when exposed to others.  Practice physical distancing all of the time.  If you have any symptoms, do not go to work or places where you could infect others.  Assume everyone you meet has the virus and is infectious, even if they had a negative test.  

Importantly, for the upcoming July 4th holiday, celebrate with your immediate household – not with your extended family, and certainly not as part of a public crowd.  Celebrate at home if at all possible.

Please share this message broadly.  The following link can be used in any social media posting: https://bit.ly/2Zoadec.  The Wilson story is tragic, but will at least have some meaning if others learn from it.

I wish you all a safe, happy and healthy July 4th holiday.

Thank you all.