Frivolity

 

This week I have a special holiday gift for everyone. I will subject you to neither tortured analogies nor strained literary references. As I work to get myself into the holiday spirit – in this environment that is not particularly conducive to celebration - today’s theme is, perhaps ironically, frivolity.

First, our not-even-close-to-frivolous COVID-19 update for the week. The vaccine news continues to roll in, almost all of it good and encouraging. This situation is too complex and evolving to cover in this space, so please look for other communications from me or the Incident Command Center for ongoing vaccine information. Bottom line, our affiliate hospitals were incredibly supportive and collaborative when Baylor had no allocation of vaccine. We now know Baylor will be allocated the Moderna vaccine and will work to distribute it per priorities mandated by Texas health authorities.

Regarding our numbers this week, please refer to the TMC website. Community cases continue to climb at a daily rate equal to July surge levels. Nationally, weekly deaths continue to increase, as they have for the past two months. Test positivity rates, a general gauge of community disease prevalence, continues to climb. We will only recognize the peak to this winter surge when we are on the backside of it. Unfortunately, there is no trend I see that hints we are headed down.

It also feels differently. In July, I heard about people who had COVID-19. Now, I can name 5 people I know well who contracted the disease in the past week. Personally, as careful as I try to be every single day, I experienced an exposure. Thankfully, I remain negative to date, but am self-quarantining until I am certain I am in the clear. This is what a high prevalence environment feels like, and I expect it will get worse. When one person out of one hundred has the disease (a one-percent prevalence), you can roam around the community and not actually come across someone infected. When 10 out of 100 are infected, on a statistical basis, you will almost certainly come in contact with someone actively shedding the virus.

Implications for all of us? Double down on safe practices. Mask and distance. Do not congregate in indoor public places. Assume everyone – everyone – you come into contact with is potentially infectious. If you have symptoms, do not come to work, do not expose yourself to others. Be extraordinarily careful over the holidays, and avoid gathering people together from different households. If you did the detailed work over the past couple of weeks to form a holiday bubble, good for you. Make sure you stick scrupulously to the plan. If you did not, it is too late to start a bubble (unless you want to push out your celebrations into January).

Back to my theme. Frivolity. It may seem a little tone-deaf after reading the preceding paragraphs, but I will argue that a little frivolity at this particular moment is a good and important thing. We have been at this a long time. I do not know anyone who is not experiencing COVID fatigue. Rationally, we know the end is in sight, but we are still caught up in the daily grind. Our providers are bending, but not breaking, under the strain of this prolonged surge. Does life get back to normal in the Summer? The Fall? It will, but relief seems remote. Inevitably, many of us are wearing down.

This is the season of giving. All I ask of you during the holidays is to give a small something to yourself. Do something mindless and frivolous. Something effortless that gives you pleasure. Something that has absolutely nothing to do with SARS-CoV-2. I do not mean to suggest we act selfishly during the holidays (next week I will touch on giving to others), but many of you have given so much to so many over a sustained period of time, it is important to pause and make a deliberate effort to take care of yourselves.

With that recommendation in mind, I will finish by sharing with you my little bit of frivolity. Sincerest apologies to Clement Moore:

A Visit From Dr. Fauci

‘Twas the tenth month of COVID, outside the med school,
The virus was surging, making us look the fool;
Our screeners took temps and filled out our checklists,
In hopes Dr. Fauci would soon pay us a visit.

Our masks were in place over both mouth and nose,
In full PPE from our heads to our toes;
And I in my N95 – quite well fit –
Had just settled down to rest just a bit.

When suddenly I started to get texts non-stop,
I jumped on a Zoom call to see what could be up;
And who should I see in the box, upper right,
Than a crack immunologist, oh what a sight.

Bespectacled, bemused and a tiny bit grouchy,
I knew in a moment this was Dr. Fauci;
At first he was “on mute,” the mic icon all red;
But once that was solved, I recall what he said:

Now Baylor, now UPenn, now Duke and now Vandy,
On Hopkins, on Harvard, on Mayo and Emory.
Learning Health Systems – this is your finest hour,
In our battle with COVID, you hold all the power.

When we had zero testing, no testing at all,
You spooled up research labs to answer the call.
From lab bench to bedside treatments poured out tout suite,
A remarkable feat that was really quite neat.

Need a vaccine? You gave us three, four or five,
That promise did so much to keep hope alive.
New treatments emerged in a chaotic stew,
Phase three clinical trials helped us know what was true.

Young doctors in training, PAs, nurses, et al,
Learned in a pandemic, an order quite tall.
With a passion for learning that must be life-long,
CME helped all doctors discern right from wrong.

And finally, a nod to providers front-line:
This truly has been your moment to shine.
Your safety, your families, and your own burdened hearts,
All took backseat to your blest healing arts.

You battled at onset, you battle on still,
You’ll battle to the end, and please know that it will.
The challenge is not ended, it continues today,
And we owe you a debt that we never can pay.

His eyes were quite moistened, and his voice all aquiver,
He said, “thank you, thank you” for the care you deliver.
And just before clicking on “End Meeting for All,”
Added “Academic Medicine, we’re proud you’ve got this ball.”

I hope you and your family have a safe, joy-filled – and slightly frivolous - holiday.

 

(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).

 

 

COVID vaccination: My own personal risk-benefit analysis

 

This has been a truly momentous week, as the nation started mass inoculations against SARS-CoV-2. Up to now, all of our public health efforts have been around containment (which failed spectacularly world-wide) and mitigation. We should all pause to celebrate this event: the first public health intervention taken since the start of the pandemic designed to bring it to an end.

Mitigation is like giving chemotherapy to slow the growth of a cancer that cannot be cured. For the first time we have a path to actually curing our societal cancer.

When the Vaccines and Related Biological Products Advisory Committee (VRBPAC) met last week, they considered a single question: "Based on the totality of scientific evidence available, do the benefits of the Pfizer-Biotech COVID-19 Vaccine outweigh its risks for use in individuals 16 years of age and older?" They performed a risk-benefit analysis. As every probably knows by now, that answer was "yes."

Vaccine supplies will be limited at first, and there is still much we do not know about how it will be distributed. To get a rough guess of where you fall in the expected allocation plans, the New York Times published a useful widget. If you are towards the end of the line, do not worry. Like the annual melt of the Rockies ice pack, our vaccine trickle will soon become a substantial stream, and by the springtime, it will be a flood.

By April, if all goes as expected, I suspect most people who want to be vaccinated will have access to vaccine.

Suddenly, we are all faced with our own VRBPAC-like question: "Does the benefit of vaccination outweigh the risks to me?" Today I want to share my personal risk-benefit assessment.

First, I need to review our recent numbers. We remain in a major surge. We did not experience a major Thanksgiving bump, and there are some encouraging signs.  

The regional R(t) dropped below 1.0 (suggesting viral spread is decelerating) for the first time in several weeks. On an average basis over the past week, new community positive cases actually dropped (2,373 vs 2,040 for the weeks ending Dec. 6 and 13, respectively). This is encouraging, especially given this drop occurred during the time we should be seeing Thanksgiving induced spread. However, it is far, far too early to declare victory.

Numbers are still at near-record highs, and in our June/July surge we saw many examples of one-week dips followed by new-record highs. Our hospital COVID-19 census continues to inch up daily, and hospitals and providers remain on surge footing.

National daily death rates have declined for the past three days, and hard-hit communities like El Paso have seen their case rate numbers fall. Again – to be crystal clear – it is too early to say we are on the declining side of the surge.

Critically, our nascent vaccine rollout will do virtually nothing to impact the current spread. We need to maintain our viral control practices and plan for safe December holidays.

But, back to my personal risk-benefit analysis.

On the risk side, my personal assessment of the risk if very, very low. I will confess, I have confidence the clinical trials process, and in our regulatory approval processes. A collection of our best clinical and scientific minds has looked at the available clinical trial data, put it in the context of decades of experience with rolling out new vaccines, and concluded it is safe and effective.

I have confidence in our own Baylor vaccine scientists and infectious disease experts, who have independently looked at the available data and are comfortable with the vaccine's safety profile. I have also reviewed the data myself, which is publicly available. I encourage you to do the same.

More than 40,000 people received the vaccine in the Pfizer trials. The subjects included people with a range of chronic conditions - diabetes, pulmonary disease, heart disease, hypertension and others. The most common adverse reactions were local soreness at the injection site, headache, muscle pain chills and joint pain. I am not even sure I would classify these as "adverse reactions." They are signs your body is mounting an immune response, which is what a vaccine is designed to do. There were no major adverse reaction reported.

Once actual non-trial vaccine administration began in Great Britain, there were two widely publicized allergic reactions. I have not seen the details reported yet, but both individuals apparently had a history of severe allergic reactions and carried Epi-Pens. At this point, if you have a history of severe allergic reactions (trouble breathing, skin rash) out of an abundance of caution I would suggest you wait to be vaccinated. I believe there will be much more clarity regarding these reactions in the next days to weeks.

In summary, the rate of a significant adverse reaction is very, very low. There have been no deaths, and even the two allergic reactions were easily treated. I am personally very comfortable with this level of risk. However, I am respectful of those who remain cautious. My advice. Wait a month or so. You do not have to get vaccinated today. The vaccine was approved based on the experience of tens of thousands. Within a week, our experience will expand to hundreds of thousands. Within a month, millions. If our experience continues to hold when a million people are vaccinated, I am probably far more likely to be severely injured driving my car to work than I am to experience a major vaccine-related complication.

That is my assessment of my risk. What about my perceived benefit?

Part of my motivation is – as I think it is for most early adopters – at least partially altruistic. I have no major risk factors. I do not want to get the virus, but I am vigilant about my distancing practices and do not necessarily fear contracting it.

However, I do feel – especially as a physician – an obligation to receive the vaccine. In a very small way, I am protecting the more vulnerable in our population. It will require tens of millions of individual small decisions to see this end.

I will confess, much of my motivation – much of my perceived personal benefit – is selfish. I have an 82-year-old father in North Carolina I would like to be able to visit without fear of infecting him. I have a niece and nephew – three-year old twins – I would like to see in person rather than on FaceTime. I have two "pandemic baby" granddaughters that I want to steal from their mothers ever now and then to have small adventures together. I want them to be able to meet and play with other children their ages. I want to go to church on Sunday morning in vivo, instead of on YouTube.

As I write this, it strikes me that this is not particularly revelatory – the pandemic has robbed all of us of something important. Health. Economic security. Companionship. Human connection. Selfishly, I miss my pre-pandemic life, and want it back. My individual decision to receive the vaccine will not get us there, but millions and millions of individual decisions will.

Let's get our lives back.

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).

 

 

Heroes (are sometimes not who you think)

 

Shortly before I sat down to write this message, 90-year-old Margaret Keenan quietly stepped out of anonymity and into the history books as the first person in the world to be vaccinated against COVID-19. One down, a few billion to go.

It is said that a journey of a thousand miles begins with a single step. On our journey to world-wide herd immunity, we just took a small but critical step. Ms. Keenan performed a very small act of personal heroism, in a pandemic that has been marked by countless acts, large and small. Today, I want to highlight some of our less visible heroes at Baylor.

First, a word about vaccines and our current numbers. Just a word about vaccines, because there will be many words to come. There is still much we do not know, and the situation is constantly evolving. As we have information, we will push it out to our community. It is my goal that you know what I know. As vaccines become available to Baylor and our affiliates, we will get everyone vaccinated as rapidly as possible.

For now, I would offer a few general comments. First, if you are presented with an opportunity to be vaccinated, take it. Many in the Baylor community, especially those involved in direct patient care, will be vaccinated by our affiliate institutions. Second, initial supplies of vaccine will be limited and prioritized in line with CDC and State of Texas guidelines. Be patient.

It appears likely the initial trickle of vaccine supply will grow to a steady stream– I am confident we will have ample supply for our needs in the next couple of months. Finally, and critically, this is not over. I have to confess it gives me an incredible sense of relief that we are finally doing something to end this collective nightmare. For the first time, we are not just bailing out our sinking boat, we are repairing the hole in the hull. But until we get a substantial portion of the population vaccinated – probably sometime in the summer – we cannot relax our discipline around masking, distancing and safe viral control behaviors.

Our numbers bear out the need for continued vigilance. Last week, on an average daily basis, Harris County and surrounding communities added new COVID-19 cases at a rate of 2,373 per day, an increase of over 350% in eight short weeks, and a rate that exceeds our previous July peak. During that same eight-week time period, new admissions to hospitals grew to 174 per day, an increase of “only” 69%. The relative slow growth in hospitalizations compared to community cases is a bit of positive news, but the flood waters are still steadily rising at this point. Our hospitals and providers – our front-line heroes – are once again feeling the strain.

I wrote about those front-line heroes – our physicians, nurses, trainees and other providers – almost four months ago. They described to me their personal anxieties and sacrifices, but also their sense of pride and joy of teamwork in battling the pandemic.

As I said, today I want to try and recognize another group of essential personnel – those at Baylor who keep us safe. Those who keep us fed and keep our work environment clean. Those who keep our buildings in good repair. 

These are people who cannot do their job on Zoom; people who quietly and without fanfare show up day-in and day-out to do what needs to be done. In preparation for this piece, I spoke with about a half-dozen of these folks – people working in security, housekeeping, facility maintenance, the front desk and the cafeteria. Here is what they told me – their words, not mine:

How has the virus impacted your life? What are your greatest fears or anxieties?

• I worry mainly about my family. I have an elderly parent I want to protect.
• I no longer take my health for granted. I am not as young as I used to be, and I worry about my outcome if I did catch it.
• One of my cousins died – he didn’t take it seriously. I have other family members with medical problems. I need to protect them, and I need to protect my grandchildren.
• I take this very seriously. I am much more obsessed with cleanliness at home. I wear a mask, and I keep my distance. No one visits our home anymore – FaceTime and telephone visits only.
• I know many people who have lost their jobs and are suffering economically.
• I feel isolated. I am used to visiting my family regularly, and I like to go out dancing a few times a week. Now I am always at work or at home.

Why do you continue to come to work?

• It’s my job. It’s what I do. I get up every morning and go to work.
• There are still things that need to get done. There are so many people here who are doing so much to fight this virus. They have needs, and it makes me proud to help.
• People at Baylor are so smart and so educated. I learn something every day when I come to work.
• I need to eat…I have to work!
• I feel safer at work than anywhere.

What gives you hope?

• The vaccine!
• We are doing a good job keeping people safe. I work screening people as they come into the building. A few people still give us grief. Please tell them we are just doing our job.
• I know by protecting myself I am protecting other people.
• My faith. God will keep us safe.
• It has been an incredible time. I have seen great teamwork and great planning turn into action in record time.
• Everyone is working towards a cure; I am proud of the work Baylor is doing on behalf of our community.

After spending time discussing experiences with front-line healthcare workers and representatives of our support staff, there are certainly big differences. However, I am struck more by the commonalities. Concern for family. Hope for the future. Pride in the role Baylor College of Medicine – more specifically, the people of Baylor – has played in this struggle.

I will close by asking a favor. When you are at work today – at your desk, in your lab or classroom, walking the hallways – stop for a moment. Look up. There is someone you have seen day-in and day-out. Someone keeping you safe, keeping you fed, keeping you comfortable so you can do your work.

Say thank you.

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).

 

Winter is Coming

 

Do not give up on this message after the first couple of paragraphs. It starts out bleak, but I promise it will lighten up by the end.

There is much to be concerned about this week. Nationwide, the U.S. has reached record highs of new infections. El Paso is experiencing a major surge, airlifting ICU patients to hospitals around the state and providing medical care in a field hospital in its convention center. Our local TMC data continues to show the same pattern it has for the past four weeks – a slow but steady rise in new community cases; a slightly slower, but also steady increase in hospital admissions. Are we headed for another surge, or are we in some tenuous equilibrium? If this were a flood, most of our neighbors’ houses have already flooded. We hope ours will not, but quietly believe it will. The Biden transition team has taken warning of a “very dark winter,” to my ear a depressing mash-up of Mother Teresa’s “dark night of the soul” and Game of Thrones “winter is coming.”

My personal belief is we will surge again – in fact, we already are. I do not believe we will reach our July peak levels. But – and this is an important “but” – no one really knows. We are in uncharted territory, which is the most maddening thing about this crisis. We are never sure if the worst is behind us, or yet to come.

Yet, even if the worst is to come, I remain an optimist, and there is rational cause for optimism. We have been here before. In early June, our numbers were creeping up and the future was murky. It turned out that we had a very difficult late June and July, briefly becoming the world-wide epicenter of the pandemic. As we again live through weeks of uncertainty about what is around the corner, it is useful to reflect on how our community has changed in a short time. Houston is a different place than it was in June. In many ways, we are far better prepared. Here is my list; Baylor College of Medicine has been a major contributor to every item.

• Hospitals and our health care system are COVID-19 hardened. I will not belabor this point, as this has already been discussed at some length in prior messages. Our physicians have therapeutics that were not available earlier in the year. Personal protective equipment is in good supply. We have learned how to operate a safe clinical environment, minimizing in-hospital or in-office spread to health care providers. Clinical treatment and ventilator protocols are vastly improved. Having surged once, if necessary, hospitals and systems are able to reactivate existing plans rather than developing them from scratch. Our health system – Baylor and its affiliates – has learned a great deal in a short time and is better prepared. 
• Community leaders have pulled together. To a large degree, we used to be a community of silos – health care providers, the business community, colleges and universities, school systems, city and county public health services, communities of faith. In a remarkable manner, community and civic leaders across all silos have formed functional and meaningful collaborations. Leaders in our community, who were at best casually acquainted, are now on a first name basis and have each on speed dial. There are many scheduled opportunities for communication; more importantly, previously isolated community leaders have formed a broad and effective network. As a result, Houston has enhanced its ability to mount a coordinated response to a shared threat. 
• Public health capacity has improved. Although the viral load in our community is still too high to perform effective contact tracing as a containment strategy, both the city and county health departments have made substantial strides in mitigating the disease in Houston. There is a good understanding where the community hot spots are located, down to individual zip codes. Notably, led by Baylor’s TAILOR labs in collaboration with the Houston Health Department and Rice University, analysis of viral remnants in sewage seems to be highly correlated to growth in new cases. In fact, the wastewater analysis seems to provide a week or two of advance warning of developing hot spots. This gives the health department valuable time to deploy a neighborhood specific strike team to provide focused community education and testing. 
• The public is engaged. As noted above, El Paso is surging for the first time in the pandemic, while our numbers are more modest. One of the big differences is our adoption of masking and distancing. I took my granddaughter to the zoo this weekend – with a degree of trepidation – and was gratified that everyone was wearing a mask. Timed entry helped to keep the crowds down, and it was easy to maintain distancing. I believe the severity of our crisis in the summertime won many converts to the importance of masking and distancing. There are clearly exceptions, but individuals, businesses and public institutions that continue to take the threat seriously are helping to protect the entire community. If we avoid a repeat of our mid-summer surge, it will be thanks to the people of Houston. 
• All we had was a switch, now we have dials. When the rodeo closed, the pandemic was its infancy, and our knowledge was severely limited. Many leaders felt the only prudent course of action was a broad and prolonged shut down of most activity – closure of schools, businesses, places of worship, etc. Now we know much more and have a great deal of accumulated experience. If we experience another major surge, it will result in another series of governmental restrictions on activity. I hope this does not occur, but if it does, I expect the restrictions will be far more nuanced, focused and time-limited than earlier in the summer, with less social disruption and less economic impact.
• Vaccines are on the horizon. Based on the preliminary but good news emerging from Phase III clinical trials, it appears the nation will have at least one – and likely more – safe and effective vaccines available by early next year. Many will be disappointed that the introduction of a vaccine will not lead to an immediate declaration of the pandemic’s end. There will be production and distribution challenges. It will still take several months of to achieve herd immunity on a national scale. Masking and distancing will be with us for some time to come. However, earlier in the summer, we were having an “if” vaccine conversation. Now we are discussing “when.” We will have an important new weapon in this battle in the near future.

So, I am hopeful. It is not a hope born of desperation. It is a hope born of the confidence our team has been here before and proven our resilience. It is a hope born of pride that the College always rallies to support the people of Houston. It is a hope born of knowledge that there will be an end to this crisis, and that we will emerge stronger than ever.

Stay well and keep your guard up. We will get through this.

(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).

 

Build Your Holiday Bubble

 

This week, we seem to be stranded in COVID-19 purgatory. In the Houston region, new community cases are slowly inching up, as are new hospitalizations. The trend is concerning enough that most TMC hospitals are dusting off their surge plans in the event our health system is once again stressed. We still do not know if we are in the early phase of another exponential growth cycle, or at a precarious equilibrium. Based on recent stressors in our community, I fear it is the former. Public schools reopened for face-to-face instruction this week in Houston and other areas, the shorter days are driving people indoors and many are experiencing mask fatigue. In addition, much of Europe is experiencing a surge rivaling the first one, and reinstituting lock-downs. Much of the US, particularly in cooler regions, is also surging. I think we must assume we are in the early phase of another regional battle with SARS-CoV-2.

I know this is demoralizing for many, especially as we approach the holiday season. Many have given up so much already. Our lives have been disrupted by the pandemic in ways large and small. Should we sacrifice time with family and close friends over the holidays as well?

For a little ray of hope, I look to the recent NBA season. The NBA created a “bubble” in Orlando, played all their games, and completed their post-season. Lots of comingling of people, plenty of close, mask-less physical contact. How many infections since the NBA resumed regular season play in August? Zero. None of us have the resources of the NBA, and we cannot replicate their bubble (they tested everyone daily and took over entire luxury hotels). However, I believe it is possible to create your own “holiday bubble” and have a relatively safe and responsible time with family. Following the lesson of the NBA, forming an effective bubble requires planning, commitment and attention to detail.

Before we dive into the details, I need to start with a couple of significant disclaimers.

First, you need to honestly assess your own risk tolerance. The only way to remain completely safe is to remain maximally isolated. If you are elderly, immunosuppressed or have a serious underlying medical condition, you need to weigh the risks of holiday celebrations against the potential benefits. Creating a holiday bubble will help to minimize those risks, but cannot eliminate them.

Second, creating a holiday bubble is possible, but it will not occur without real commitment of all participants. One weak link will breach your bubble. Half-hearted commitments will only lead to a dangerous false sense of security. If everyone is not committed, you are probably better off celebrating exclusively with members of your usual household, and not mixing with family and friends from down the street, or across the country.

With those disclaimers in mind, here is my suggested process to create your own holiday bubble. It has specific tasks that must be performed on schedule. Count backward from the day your family plans on entering your holiday bubble to establish your timeline.

Today

• Get your flu shot. This will decrease the likelihood of developing a flu-related illness around holiday time, which could disrupt your plans.
• Have a serious family conversation. Do we want to commit? Are we willing to create and maintain a safe environment? DO NOT SKIP THIS STEP. Obtaining real commitment to form your bubble is the single most important part of this process:
• Who is at high medical risk in our family? What is our risk tolerance for exposing them in a family get-together? If your risk tolerance is low, even a bubble may be too risky for you.
• Are we committed to doing the substantial work necessary to create a “holiday family bubble?”
• There is variability in how seriously people are taking precautions. Beginning two weeks before you come together, is everyone willing to rigorously adopt good viral control practices? (mask, physically distance, avoid crowds). Your bubble will only maintain its integrity if everyone is fully committed. If you have a family member that cannot commit, they cannot be safely invited to your holiday bubble.
• Have everyone print the Holiday Bubble Checklist. Or, view a Spanish version. 
• Assign a Family Bubble Commissioner, a single individual who will take responsibility for reminding bubble participants of key milestones and encouraging compliance.
• Sign a family pledge. I know this may seem a bit overboard to some, but obtaining commitment is critical.
• Agree on a location. One of the best options is a private home where everyone will come and stay. It would be ideal if the location included some outdoor space, weather permitting. Keep in mind, this will be your bubble. Once everyone arrives, you are there to stay. No excursions, no visitors. Once in the bubble, you stay in the bubble.
• If flying, order face shields or goggles to protect your eyes, which are a potential portal of entry for the virus. Consider trying to obtain N95 facemasks. Cloth masks used in combination with eye protection afford an acceptable level of safety, equivalent to the protective equipment used by health care workers during routine hospital care. An N95 combined with a face shield or goggles would provide maximal protection, and is equivalent to the equipment used by health care workers when dealing directly with known or suspected COVID-19 patients. Regarding eye protection, either a plastic face shield or eye goggles are effective. Goggles must fit snugly. Air purification in many planes is excellent, but varies based on the airline and model of aircraft.
• If flying, take a direct flight if possible.
• Check any travel restrictions for the state that you will be visiting. Note many states have restrictions and quarantine requirements. Some international destinations have testing requirements. Remember to check the regulations for the state to which you are returning after the holiday as well.

Two weeks (14 days) prior to holiday:

• Everyone planning to enter the holiday bubble must make extra effort to limit contact with other individuals to reduce risk of exposure.
• If your job duties permit, work from home. Self-quarantine. Important: Quarantine is more than being cautious. It means staying home and avoiding all contact with anyone outside your regular household, even if masked.
• If self-quarantine is not possible, maintain scrupulous attention to distancing and cloth masking along with hand washing/sanitizing.
• Add a plastic face-shield or goggles to your cloth mask when you are indoors and in contact with others. Note, the face shield is in addition to, not in the place of a cloth mask.
• Daily symptom and temperature monitoring. If you become symptomatic or have any fever (even low-grade), seek evaluation by a physician and tested with a PCR test (for this purpose, avoid rapid tests). If your test is positive, cancel your participation in the bubble, along with all others who live in your household.
• Decide who will be cooking during the holiday. Stock up on non-perishable food items in advance.

5-7 days prior to holiday:

• Get a diagnostic test (PCR, not a rapid test). If positive, cancel your participation in the bubble, along with all others who live in your household.
• Stock up on hand sanitizer and disinfectant wipes for travel.
• Complete your food shopping. If you plan to drive, buy travel food in advance. Purchase perishable items for your holiday meal(s). Remember, you are quarantined. Use a grocery service with touchless delivery to maintain your quarantine status.
• Recheck travel restrictions.

Traveling to the bubble:

• Drive if possible.
• Make the trip in a single day if you can do so safely.
• Bring your own travel snacks
• Limit time in -- or avoid altogether -- crowded roadside fast food restaurants, truck stops, etc. Mask and distance when out of the car. Consider adding a plastic face shield in addition to a cloth mask.
• If you must fly:
• Wear a cloth mask (or N95 for maximal protection) and a face shield or goggles. Remember, eye protection is in addition to your mask.
• While on the plane, leave your mask and face shield/goggles on as much as possible. Ideally, they should stay in place for the entire flight.
• Skip the snacks and drinks.
• Use the restroom prior to boarding.
• Limit fluid intake for 30 minutes prior to departure, and during relatively short flights (two hours and less).
• Avoid use of the airplane lavatory. If you must use the lavatory, keep your mask on, and wash your hands thoroughly.

During the holiday

• If you are confident everyone has followed the above guidance, you are relatively safe in your bubble. Continue to use common sense. Play games, eat, sing songs, throw the football. Enjoy fellowship with (bubble compliant) friends and family. After all your hard work, planning and preparation, you can relax and enjoy the holiday.
• For high-risk family members (elderly, immunosuppressed) it is probably prudent to continue to follow good masking, hand hygiene and distancing practices.

This is not easy, but what in this pandemic has been easy? Decide who is in your holiday bubble, and start the conversation today. If people are committed, begin the process as outlined above. Do not skip steps.

Let us try and spread this message. If most of us create a bubble, we can minimize the risk that the holidays will become a super-spreader event, and we can keep our loved ones safe.

Take the pledge. If you are on Twitter, post when you have committed to creating your bubble using #HolidayBubbleBCM. Encourage others to do the same.

I wish you all safe holiday season, and one filled with companionship and love.

 

(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).

 

 

Never Give Up, Never Surrender

 

Imagine a crisis in our community.  There is much about the crisis that makes it difficult.  The threat hangs over us continually; we can put it out of our minds temporarily, but it is always there in the background.  It strikes indiscriminately, causing death and disability to young and old alike.  Our best protection is defensive – everyone must modify their behavior to help keep all people safe.  As rigorously as we play defense, it does not eliminate the threat, and we yearn to go on offense.  We want an effective intervention that repels the invader, so we can return to our normal life.

SARS-CoV-2 and COVID-19?  As horrible as the global pandemic has been, and all the medical, social and economic turmoil it has wrought, I am describing the bombing of England during the Second World War.  From roughly June of 1940 to May of 1941, the English people endured a near continuous threat of death from the air.  In total, the nighttime bombings left 43,000 civilians dead, and more than three times that number wounded.  I just finished reading Erik Larson’s "The Splendid and the Vile," an excellent book that covers this period in history in a focused and engaging manner.  As I was reading, the parallels to our current crisis were unavoidable.

There are two major themes to the book.  First, in spite of the intermittent terror the population faced, life went on.  Weddings and baptisms; theater and music; the daily rhythms of work and school.  The English people endured incredible hardship, with no end in sight and the constant fear of invasion.  And life went on.

The second theme is the importance of leadership – specifically the role of Winston Churchill, who ascended to the office of prime minister during this most challenging time.

Churchill clearly had feet of clay: massive personal debt, probable over-indulgence in alcohol, odd personal boundaries (he was known to dictate correspondence to his secretary from the bathtub), quirky behaviors (he liked to wear a pink silk robe around 10 Downing Street) to name a few.  He was not perfect.

But he was a leader for that time.  He was masterful in his communication to the public: honest about the hardships faced and uncertainty of the situation, while maintaining a sense of unbridled optimism.  He dealt and managed in an environment of uncertainty (Will the U.S. enter the war? Will the Germans launch a land invasion?).  He assembled and maintained an effective leadership team.  He regularly visited sites of devastation.  He connected to, and wept with, the people.  He seemed to almost literally pick the nation up, and carry it through a horrific ordeal.

As I continue to monitor our COVID-19 metrics, and prepare to go to the polls to early vote, it is appropriate to pause and consider the importance of effective leadership.

The news out of Houston this week is a mixed bag. No one has a crystal ball, but on balance, I am discouraged by our numbers and believe we are on the cusp of another surge.  Although there is good news (the City’s test positivity rate is down to 5%), a number of our metrics are worsening.  From the TMC data, our R(t) value, after 32 days of staying below 1.0 (virus receding), snuck above 1.0 (virus is expanding).  New daily cases in the greater Houston area remain stubbornly in the 400-500 range, and the daily rate for the past three weeks is edging up (373, 394, 412).  New hospitalizations are increasing, albeit at a slow rate (0.9% daily increase) and the total census of COVID-19 patients in TMC facilities is again rising (1.3% daily).  Data from the Baylor diagnostic labs show the positivity rate increasing, along with the average viral load of specimens, a sign that the tested individuals may be more infectious.  There is increasing evidence that young adults (20s and 30s) are responsible for much of the spread.

I am afraid we will see the viral resurgence in the coming weeks, as are many regions across the world.  I hope I am wrong.  I hope the surge does not come, and if it does, that it is not as severe as we saw in July.  Let us all do what is within our power. Continue to beat the drum: mask/distance/avoid crowds.

As we prepare for a potential resurgence, and reflect on the role of leadership in crisis, I want to try to channel some of Churchill’s clear-eyed, realistic optimism.  I want us to come together, not be torn apart.  To that end, I have three specific requests of you today.

• Vote.  Do not wait until the last minute, do it this week.  Democrats and Republicans; liberals, conservatives and libertarians; supporters of “big oil” and the Green New Deal.  “MAGA-fanatics” and “Never-Trumpers.”  Vote.  We are living in divisive and turbulent times, but the nation has seen and endured worse.  Over time – if you participate – our system will work.
• Reach out to your Churchill.  We have all suffered through the pandemic, some far more than others.  I imagine everyone at some point has experienced a degree of anxiety and uncertainty; some have felt real despair.  Stop and reflect for a moment on who has helped you through this difficult time.  It may be a co-worker, supervisor, faith-leader, family matriarch/patriarch, teacher or civic leader.  Focus especially on those who are quietly leading out of the public eye – those who lead but do not get recognition.
  
  Now recognize your Churchill.  Right now, sit down and write them an e-mail.  Tell them how important they have been in helping you through this difficult time.  Tell them how they helped you.  Better yet, write them an actual letter.
• Start a global pandemic of support.  We are battling the “R(t)” and the pernicious nature of exponential viral spread: one infects two, two infect four, four infect eight, etc.  
  
  Let us try to create exponential growth in support of each other.  Share this message with two other people and ask that they send a note of thanks to their Churchill: the person that has helped them most through this time.  Then ask that they encourage two others to do the same.  Not as a social media campaign, not as a meme, not as a hashtag. Privately, individually, sincerely.

At the risk of beating this theme to death, I will finish with Churchill:

“We shall not fail or falter; we shall not weaken or tire.  Neither the sudden shock of battle, nor the long-drawn trials of vigilance and exertion will wear us down.”
 
Stay well (and vote!)
 

(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).

 

 

 

Bears and Bulls and Bars

 

It is never a good sign when I am writing my Wednesday message on Thursday morning. My intent this week was to write about bar openings. However, events have evolved so quickly, two versions of this message are already obsolete. Instead of rehashing the recent news, I will refer you to a couple of sources if you want to dig deeper into the issue.

I am going to focus on broader questions: Is it time to reopen bars in Harris County? (No); What role should personal responsibility play in community control of the virus? (A critical one); How are we doing in our efforts to have a civil, respectful public debate? (C+, but I tend to be an easy grader).

First, a couple of references for background reading. There is an article in this morning’s Houston Chronicle that does an excellent job summarizing the issues around bar reopenings. I would recommend reading this if you were under the mistaken impression bars were already open.

If you are interested in this topic, I would also encourage you to read Gov. Greg Abbott’s actual executive order (GA-32).  It is a detailed document, which makes attempts at a degree of nuance. For example, when drinking in a bar you must remain seated. That is, unless it is a wine tasting, in which case you may stand “if in a group of six people or fewer and there is at least six feet of social distancing or engineering controls, such as partitions, between groups.”

At a very high level (please read it for yourself) the Governor’s order a) permits bars to open at 50% of total listed capacity, b) but only in counties that do not have an excessive burden of COVID-19 in hospitals and c) in a major digression from prior executive orders, requires the county judge to opt-in to the reopening decision.

So should we reopen bars? First of all, let us acknowledge at this point in the debate, most of us are either viral bulls or bears. The primary concern of the bulls is economic. Government mandated limitations on businesses create hardship and long-term damage to the social, economic, emotional and medical well-being of people. Others are viral bears. Failure to adequately mitigate the virus in communities via public health measures, including limitations on businesses, will result in preventable death and a repetitive cycle of shut downs, reopenings and surges. There is validity to both positions. I work for an organization whose explicit mission is to improve healthcare. I acknowledge my bias – I am a bear, and suspect most, but by no means all of my colleagues, are similarly inclined.

Why is now not time to open our bars? Our numbers are stable to improving. Our R(t) has been less than one (indicating the virus is receding) for more than two weeks. Community cases (which we want below 200 per day) seem to have stabilized between 300-500. As I have previously reviewed, I have some apprehension this number is under-reported due to Texas DSHS data reporting challenges. New daily hospitalizations (probably a more reliable, but indirect estimate of disease prevalence in the community) are 20-25% of what they were during our July surge, but seem to be trending slowly upward over the past week. At best, our monitoring metrics are at a tenuous equilibrium. At worst, we are in the early phases of exponential growth. The unfortunate reality is we will only know which condition is true – best case or worst case – looking in the rear-view mirror.

Our numbers look relatively good, but the experience around the world should drive us to act cautiously. If we are too exuberant in our path back to normalcy, we will surge again. And shut down again. Critically, we are getting ready to stress our system further. School systems and parents still need to make decisions regarding a return to face-to-face instruction. Cooler weather will drive people indoors and will probably promote viral spread. Our equilibrium can only withstand so much perturbation – let us focus on getting children back in schools before we reopen bars.

A word in support of bar owners. Many are tax-paying small business owners, with personal investment in their enterprise. They employ Houstonians. They have families to feed. They are no longer receiving any government assistance to help mitigate the impact of government-ordered restrictions on their businesses. Their expenses continue, even though their revenue has evaporated. The rent still comes due. Those of us who had the good fortune to remain employed through this crisis should be careful not to vilify those who face a choice we have not had to make – close up shop, or find a way to do business in the challenging pandemic environment.

Gov. Abbott’s executive order creates some clarity, but in Harris County is likely to stoke political debate as to next steps. Should Judge Lina Hidalgo – clearly a “bear” – opt-in or opt-out? Most of us will have an opinion heavily influenced by our bullish or bearish inclinations. There will be passionate declarations made from both extremes. What can we all do to help drive a good outcome for our community? A few thoughts:

Proprietors of bars and restaurants:

• Demonstrate to those of us who are justifiably worried about the resurgence of this disease that you are taking it seriously. Most of the business community has, and we thank you. Some clearly have not.
• Look at your space. Create visual cues like floor markings and furniture placement to encourage distancing. Require masking upon entry. Creatively use outdoor spaces. Regularly walk the floor of your business, and critically assess if your patrons are effectively distanced. Do more than meet the technical requirements imposed by restrictions; meet their intent.
• Use the opportunity to innovate. Build your take-out business. Develop home mixed drink kits. Hold virtual on-line wine tastings, pre-selling the wine. I do not pretend to understand your business, or what is required to remain profitable, but I believe it is a risky strategy – from a business and public health perspective – to tie your economic recovery to packing people into a confined space.

Patrons and the general public:

• Reward those businesses – bars included – that are doing this well, and making a sincere effort to keep the community safe. Patronize them if they appear safe. Order take out. Tip generously. Tell your friends and colleagues when you have an enjoyable COVID-responsible experience.
• Remember, no matter how carefully crafted an executive order or local mandate might be, regulation will never be enough to ensure your safety. To repeat an analogy I used a couple of weeks ago: The government tells me how fast I am allowed to drive. I make a conscious decision to slow down when visibility is poor, because I have good situational awareness, and I am concerned about the safety of those around me. The same goes for viral safety. Stay alert and aware. If you walk into any environment and people are crowded and unmasked, turn around and walk out.

Americans/Texans/Houstonians:

• In what has become an increasingly divisive environment, let us all work to take the temperature down a notch or two. I freely acknowledge as a professional working in health care, I lean towards the “keep people safe and healthy, prevent the spread of the virus” side of the debate. I am a viral bear. I hope I have empathy for those who have experienced severe economic impact from the pandemic, who are justified in their desire to see things reopen as rapidly as possible. I hope I have respect for the informed opinions of bulls. There is a tension between these worldviews. In a democracy, that tension is a good thing – it helps drive better decision-making. It helps, that is, if we are actually listening to each other. Both sides – let us concentrate on listening more, and shouting less.

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).