We all need to do our part   

By Dr.  Tom Dean

December 2, 2020  

So how are we doing in the Covid battle.  The answer – not very good - but a little better than we were last week.
 
South Dakota still has the second highest per capita rate of new cases in the nation (North Dakota is still higher – Wyoming and Minnesota are close behind).  However, that rate has declined by 11% over the past week and the trend for the past several weeks has been downward.  The Covid death rate in South Dakota is also one of the highest but that too has moderated somewhat.  Decline is good but the rate is still much too high.
 
The first death in South Dakota attributed to Covid 19 was on March 11, 2020.  By November 28 that number had reached 942.  The pace of new deaths has accelerated at an alarming rate.  After that first death it took 6 months for the total to reach 210 on September 24 (1.1 deaths/day).  Subsequently, it took  only 37 days for that number to double to 437 on November 1 (6.1 deaths/day). In the  27 days from November 1 to November 28 the number  more than doubled again to 942 (18.7 deaths/day).
 
All this means that even though we have seen some recent leveling and decline, we are still in the midst of the worst phase of this war.  There is complete consensus among the authorities that this accelerated rate will continue through the holidays and probably beyond.
 
Covid “fatigue”  and mixed messaging from some leaders  continue to present obstacles to effective virus control.  Too many of our fellow citizens either do not understand or simply reject the concept that each and every one of us has to take part in the fight to reduce the spread of Covid.  This means, first and foremost,  all of us need to accept the fact that masks should be worn whenever one is meeting other people. Keeping separation between people and hand washing provide additional protection.
 
Concern about the severity of this surge in infections has led the three major health systems in our  state (Avera, Sanford and Monument [formerly Rapid City Regional]) to join forces along with ten other public organizations  to lead a campaign known as “Mask Up So Dak” to promote Covid prevention practices. 
 
Along the same line several of us put together a letter to the citizens of South Dakota asking each and every one to help reduce the spread of Covid.  By simple behavior changes – masks, distancing, etc. – each of us can do our part to protect our loved ones and our communities.  We were immensely gratified that, with the help of the state medical association, the letter was supported and signed by nearly 700 of our physician colleagues.  It appeared as a full page ad in ten daily newspapers last week.
 
To win this war we all need to do our part.   Smokey the Bear says “only you can prevent forest fires.”  In the Covid war the message is the same - “only you can prevent the spread of Covid!”
 

Let’s take a step back   

By Dr. 
Tom Dean 
November 25, 2020

Discussions about Covid-19 and mask wearing go on.  The debate has sometimes been  contentious and has even led to legal action.  Several weeks ago a fellow had to be escorted out of a Mitchell School Board meeting by security because he objected to a mask requirement.
 
Let’s take a step back. Why are masks important?  The main reason masks are recommended by every major authority is that they reduce the chance of spreading the virus from someone who is infected - and may not know it – to those around them.  Recently the CDC has extended their advice to say that masks also provide protection for the wearer against contracting the virus.
Not long ago, Dr. Robert Redfield, Director of the CDC, in testimony before Congress, held up a simple clinical mask and said “this is our single best weapon against the spread of Covid 19.”  Even though Gov. Noem has expressed some skepticism about mask wearing the web site of the S. D. Dept. of Health states, “Everyone  (emphasis mine) should wear a cloth face cover in public settings.”
 
I think it is truly  unfortunate that mask wearing has become as controversial as it has.  I fear we have  approached the issue in a legalistic, regulatory manner and have provoked push back.  Push back  from  folks who I suspect are not necessarily inclined to be difficult and who really do not want to be responsible for spreading virus to their neighbors.
 
The reality is that the Covid pandemic is a threat to all of us. It is more dangerous to some than others but – and this is important – everyone, young and old, healthy and not so healthy can contract the virus, carry it and spread it to others,  often without having any awareness that they are doing so.  None of us can ever be sure that we are not carrying the infection. That is the reason why it is so important for all of us to don a mask even if we think it is totally unnecessary.
 
We are in a war, a war like none of us has  seen before.  If we are to win that war it will require all of us to help.  Solid scientific evidence shows that wearing a mask reduces the chance that one will spread the virus by 60%.  That is enough to produce a major reduction in the outbreaks we see.
 
Wearing a mask is an inconvenience.  I don’t like wearing one and I am happy when I get home and can take it off. It is, however, a way for each of us to do our part to shorten the time when we can get back to a more normal way of life.
Please – find a mask and wear it.  All your neighbors will benefit.

No end in sight?   

By Dr. Tom Dean 

November 18, 2020

Covid 19.  Is there no end in sight?  I would submit that we are all sick of hearing about Covid problems. I am. Are we never going to be able to go where we please, when we please and get together with those we want to meet?  I am confident we will get back to those days. Right now, however,  it looks like that time is months  in the future – maybe longer.

Experts have long predicted  that the disease would get worse as we moved  into the fall and winter. Those predictions are now coming true.  Across the nation, in South Dakota and even in Jerauld County the number of cases is  rising at a rate that is quite concerning.

In the US we have seen an 80% rise in new cases over the last 14 days.  This has been accompanied by 38% increase in deaths which are now well over 1000 deaths per day.

In South Dakota on Nov. 14 the number of new cases was 30% higher than  the previous 14 day average.  We had an average of 15 new deaths per day which is a dramatic 66% increase over the previous two week average. These numbers compare with an average of one death per day during the summer, four deaths per day on  Oct. 1 and 9 per day on Nov 1.

In  Jerauld County, as many readers will remember, we had a surge of cases, and deaths, in late September. Things then seemed to calm down and through most of October our numbers were relatively low.  However, since November 1 the numbers have started to increase and are clearly on the way up.  They have not reached the level of mid-September but the trend line is worrisome.

What to do?

First of all we cannot let down our guard.  The virus is all around us and the minute we relax it will attack.  The most basic problem is that it is invisible and it moves around silently.  At any given time we do not know where it is or where it is not.  

We have gotten very encouraging reports about  the success of the vaccines that are in the final stages of development and testing.  One company has reported  preliminary data showing a 90% level of effectiveness.    It does, however, require 2 doses 3 weeks apart and storage has to be at -100 degrees F.  –  a level which is not currently available in most hospital and clinic facilities.

So, once again, what to do?

In my view  the best approach for all of us is to act as though we assume we carry the virus.  In fact, since this infection is so often asymptomatic and since it often appears in unexpected places, it is very hard for any of us to be really confident that we are not infected.  A very large portion of the folks who contract Covid  have no idea where they picked it up.  This means that most likely they encountered an asymptomatic carrier who passed the virus to them without ever knowing it.

If we all act as though we are virus carriers it is more likely that we will wear a mask when in contact with others and we will be more cautious about socializing in larger groups.

For those who object to wearing a mask I would make the following plea.  We are all in this together.  Any of us can be virus carriers without knowing it. Is it not worth the minor inconvenience of putting on a mask to know that you are not the one who is spreading the virus to those you meet?

Do the basics. Protect each other. Avoid unnecessary risk.   

By Dr. Tom Dean 

November 4, 2020

So,  where do we stand with regard to this evil virus?  The answer is – not good.  For the last two weeks North and South Dakota have led the nation in the number of new cases per capita.  To make matters even worse, the number of deaths has steadily gone up.  During the summer the average number of new cases per day reported to the SD Department of Health  was less than 100.  In the last seven days the average number of new cases per day has been  more than 1000.  Along with this the number of hospitalizations has reached a new high.  In early August the number of Covid-related deaths was averaging one per day.  By the end of September the number had reached an average of three deaths  per day and over the last seven days the number has been  nine.

All this is, to say the least, not good news. Furthermore, we are heading into a season where people will be spending more and more time indoors and, with holidays coming, people will want to get together with family and friends.  These factors will clearly increase the risk of  disease spread 

What to do?  The virus is not going away.  All the evidence is that it will be with us and will be a threat for many months – possibly years – to come.  Availability of an effective vaccine – or vaccines – when it comes, will be a major improvement in our ability to  control disease spread.  The drugs that have shown some benefit – particularly remdesivir and dexamethasone – have only shown benefit for those patients that are severely ill and the benefit has been limited.  New drugs such as the antibody cocktail which Pres. Trump received do show promise but have not yet been fully validated.  

People may ask if someone receives a drug and gets better what more evidence do you need?  The fact is that humans are very unpredictable creatures.  An intervention which is helpful for one may be toxic to the next.  Furthermore, we need to know if someone improves, was that improvement due to the drug or would it have happened anyway.  We can answer these questions but studies take time.  Nonetheless it is vital that we have the information before a drug is released for widespread use.

Right now we have the same old interventions – mask wearing, social distancing, hand washing.  On this issue I know I sound like the proverbial “broken record.”  At the same time the evidence – and here we have solid scientific evidence – these practices do work.  They work but to be truly effective  they must be used broadly and consistently.

We hear about folks who refuse to use a mask because they believe it is their individual right to decide if they need it.  In normal times I would be inclined to accept that position.  These are not normal times.  If one lived by himself on a desert island  there would be no argument.  Living in a complex society requires certain limitations on personal behavior to protect our fellow citizens.  Examples include highway speed limits and prohibiting driving while intoxicated. I believe the public health restrictions related to Covid fall in that category. 

We are all in this together.  Winning this battle requires an all out public effort not unlike that which was required of the public in response to WWII.  I am sure folks complained then about shortages and balked at rationing but they did it and we won.

The  way we get through it is by doing the basics, protecting each other and avoiding unnecessary risk.  Wear your mask.

Should I get tested?  

By Dr. Tom Dean 

October 28, 2020

Should I get tested?  That is a question on the minds of many folks as the pandemic rages on and as the impact of the disease is felt close to home.

The picture continues to change. 

Two weeks ago Jerauld County had the highest rate of new infections in the state and one of the highest rates in the nation.  That has changed.  As of Oct. 25 Jerauld County had one of the lowest rates of new infections in the state.  South Dakota, however, continues to have one of the highest per capita rates of new cases in the nation – second only to North Dakota.

What about tests for Covid?  There are essentially three types of tests available.  The most well-established test is the so-called PCR test (PCR for polymerase chain reaction).  This is the most reliable test available.  The drawback is that it requires very specialized instruments and can only be done in a fully equipped medical laboratory.  Early on, and in some places still,  there was a serious lack of lab capacity  which led to long delays in getting results.

Recently we have gained access to what is known as antigen testing – sometimes called the “rapid test”.  This test can be completed at the clinic or hospital where the specimen is collected with results  available in 15-30 minutes.  The test has a high level of accuracy with regard to positive results but it  does sometimes give false negative results.  This is a concern because it means that a person with a negative test  will think they are free of the virus when in fact they are actually infected.  Locally, we have been submitting all negative specimens for confirmatory PCR testing and have found 10 – 20% of initially negative tests were in fact  positive.

The third category of tests is the antibody test.  This is a blood test in which antibodies to the virus can be identified and measured.  Since it takes the body 1 – 2 weeks to generate an antibody response once an infection occurs,  this test is not useful in detecting new infections. It is, however, useful in identifying people who have had the infection and who presumably are protected from a reinfection. In  some situations that would be useful to know. There are, however, reports of individuals who have been infected a second time.  At this time we think that is unusual.

There have been reports that we will soon see a saliva based test which could be carried out at home much like a home pregnancy test.  Currently, that is not available.  Hopefully it will be here soon.   Such a test would provide a quick and easy way to obtain important information.

So, should I get tested?  Any one who has suggestive symptoms (fever, cough, shortness of breath, body aches) would benefit from testing especially if they are in a high risk group (elderly, obese or with underlying chronic disease).  They need to know for their own benefit but especially so they can take precautions and reduce the risk of spreading the disease.  If someone currently  is in close contact with a person known to be infected with Covid the value of testing is less.  Even with a negative test they should limit their contact with others since there is still a risk of transmitting the virus.

Exploring the concept of herd immunity  

By Dr. Tom Dean 

October 21, 2020

The pandemic rages on and, most unfortunately, we are right in the middle of it.  Over the last several weeks, South Dakota has continually had the second highest rate of new cases in the nation – second only to North Dakota.  In number of new cases per capita our rate —as of 10/18 — is nearly five times the national rate (78 cases/100,000 residents in SD vs 17/100,000 nationally).

Given the continuing challenge I find it unfortunate that some of our leaders feel compelled to downplay the situation.  Gov. Noem has reportedly stated that this increase is due to more widespread testing. She is wrong.  The number of tests has increased but the proportion of positive tests has also increased.  More tests and a higher rate of positives means more disease.  In addition, the number of hospitalizations has increased indicating more disease.

Pres. Trump repeatedly says that “we are turning the corner.”  “The end of the pandemic is just around the bend.”  To respond effectively to a threat as serious as Covid-19 we have to be honest about the real risk.  Armies that under estimate their opponents usually lose. 

An issue  which has been increasingly in  the news  lately is the concept of “herd immunity.”  Herd immunity occurs when a large enough portion of a population is immune to an  infection such that an infectious agent cannot move  freely through that population. It means that when the infectious agent — in this case the Covid virus — encounters a potential victim, more often than not, that potential victim will be immune and infection does not occur.  Most experts believe that effective herd immunity requires 65 to 70%  of the population to be  immune. Effective herd immunity does not eliminate the infection.  The virus will occasionally find a susceptible  victim.  However, large outbreaks like we are now seeing would be prevented.

Vaccination is the usual route to produce herd immunity.  Recently, however,  some commentators have suggested that allowing the Covid virus to spread in the population  without containment efforts is a preferable  way to reach herd immunity. Infectious disease experts almost unanimously reject this idea.  They  argue that this approach would result in a massive increase in deaths compared with current containment approaches.

The argument against allowing immunity to develop through natural spread of the infection goes like this.  The US population is approximately 330 million.  Antibody testing indicates that today at most 15 - 20% of the population have had the infection.  These folks are  presumably immune though the reliability and duration of this  immunity is not  clear (reinfection of patients who survived a first infection has occurred). That would leave at least  80% of the population — or 264 million — still vulnerable.  To get to an overall 70% level of immunity 165 million more folks would need to be infected.  If we figure a 1% mortality rate from natural infection that means that there would be 1.65 million more deaths.  One million six hundred and fifty thousand more deaths compared to the two hundred and ten thousand we have now — an eight  fold increase.  Not a good  trade off in the eyes of most authorities.

Herd immunity achieved through vaccination is a much preferred way to go.  Effective vaccines are coming but even when they are available it will likely take 6 – 12 months to reach the levels of immunity we are seeking.

We can defeat this virus but we need to hang together and trust the experts.  They do know what they are doing and do have our best interests at heart.

Covid-19 Vaccine Development   

By Dr. Tom Dean

October 14, 2020 

Discussions of the prospect for a Covid-19 vaccine (or vaccines) are much in the news. We know that vaccine administration has  been the major tool in the control of past threats like polio, tetanus and small pox.  There is every reason to believe that the same will eventually be true for Covid-19.  However,  vaccine development is an exceedingly complex — and sometimes very slow —process.

The challenge is to find a way to stimulate  the body to swiftly produce an immune response when it encounters the Covid-19 virus so the intruder will  be neutralized or killed.  One might ask that since the actual virus will stimulate antibody production why bother with a vaccine?  One could just wait until the virus appears and the immune response would come.  The answer is timing.  It takes the body a period of time to mobilize the first immune response. With the first exposure to the virus the immune response  may not come soon enough to prevent the damaging impact of the disease.  

Fortunately, the immune system has an excellent memory.  The role of a vaccine is to install in that memory an image, if you will, of something resembling the Covid virus.  With that image installed the body will promptly recognize the Covid virus as an invader and  will immediately begin producing antibodies.  The challenge for the vaccine developer is to find a substance that is safe to inject into humans and which will efficiently stimulate that first immune response.

Around the world many companies and organizations are working on  Covid vaccines. The progress to this point is encouraging. In the US the vaccine approval process requires three phases.  In Phase 1, the vaccine is given to a small group of healthy adult volunteers to look for any toxic side effects.  In Phase 2 – assuming Phase 1 is successful – the vaccine is given to a more diverse group of people including children and the elderly and antibody responses are measured.  If the first two phases are successful the vaccine enters into Phase 3. In this phase a very large number of people (usually in the range of 30,000) are given either the vaccine or a placebo and are monitored for two – six months  to determine if it actually prevents the disease (the presence of antibodies is not enough to assure protection).

As of Oct. 7, 2020  there were 54 different vaccines for which animal studies have been completed and are now undergoing human trials.  Eleven of these were in Phase 3 trials.  None has yet been approved for general use.

After safety and efficacy have been demonstrated the vaccine can be approved for  public use.  However, challenges remain. Several of the vaccines in trials  require storage at super low temperatures to maintain stability – equipment  not currently available in many hospitals and clinics. Many of the vaccines require two doses separated  by  three - four weeks.  Perhaps the most difficult challenge is public wariness of new vaccines.  Polls tell us that increasing numbers of the public fear there has been political manipulation of the process and simply do not trust any new  vaccine.

Vaccination against  Covid-19 is  without question the best way to achieve long term control of a virus which promises to be with us for a very long time.  Vaccine producers have made great progress in a remarkably short time but as I have indicated it is a complex process and challenges still remain.

We need to “keep the faith.”   Effective vaccines are coming.  In the meantime we cannot let down our guard.  That means understanding that the virus is all around us even if we have no sign of it.  We need to use the tools we have —  mask wearing is the most important. Social distancing and hand washing provide important protection.  Stay safe  — and protect those around you even if you do not personally feel threatened.

Immediate Covid Concerns  

By Dr. Tom Dean 

October 7, 2020

I had intended this week to present a summary of the progress toward the development of a Covid 19 vaccine or vaccines.  However, the events of the past week have raised what I believe are even more immediate concerns.

South Dakota continues to be a “hot spot.”  As of today (Sunday, 10/4) South Dakota had the second highest rate of new infections in the country – second only to North Dakota.  Jerauld Co. has now reported 100 cases.  The number just  two weeks ago – from the beginning of the pandemic until then – was 40 – a 150% increase in two weeks. Across the state the number of cases in K-12 schools has reached a new peak this past week.

Locally, the most devastating impact has been on Weskota Manor Avera  where more than half of the residents and a majority of the staff became infected in a very short time.  In my view the Manor had, by restricting visitors and by regular testing of  residents and staff, done an exceptionally good job of keeping the virus out of the facility for more than 5 months.  Nonetheless, the virus slipped in, and went on to wreak havoc. I have nothing but praise for the dedicated and compassionate care delivered  by a staff that was absolutely stretched to the max. Leaders, Administrator Nikki Von Eye and Nursing Director Brenda Easton, along with others too numerous to name, were able, through nothing less than heroic efforts, to hold things together and make it through some of the most difficult situations one can imagine.  

On a national level the situation  also appears to be getting worse.  In  37 states  the number of new cases is  rising. The underlying problem is the lack of a consistent national approach to the pandemic and the mixed messages which have come from various leaders.  The CDC officials and infectious disease experts have consistently  and strongly emphasized the importance of masks and social distancing.  Nonetheless, President Trump and his supporters have repeatedly held rallies without emphasis on either of these protections.  This was most evident at the announcement of the nomination of Judge Barrett to the Supreme Court.  One hundred fifty guests assembled in the Rose Garden, most without masks or any attention to social distancing. Eventually 10 members of the Trump inner circle tested positive for the virus.  This would clearly qualify the affair as a “super spreader” event.

Now we know that Pres. Trump himself is not only positive for the virus but is hospitalized with significant symptoms.  Details about his condition at this time are somewhat sketchy but it appears he is improving and hopefully will be out of the hospital soon.

I firmly believe that scientists such as Dr. Fauci and Dr. Redfield as well as a multitude of state health officers and infectious disease experts from across the country are giving the most sound, reliable and relevant advice.  The President and many of his supporters continue to believe that the economic costs of a pure public health approach (masks, distancing and closure of places such as bars known to be sources of viral spread) is too high a price to pay.  The mistake they make, I believe, is that no economy can grow and thrive until the virus is under control.

This is a terribly difficult problem.  There is no quick fix but we will get through it.  Effective vaccines are coming.  We do have simple tools that work.  Countries around the world that have been much more successful than the US in controlling the virus have shown that masking, distancing, hand washing  and isolating new cases and contacts are powerful and effective.

I will be blunt – and hopefully not offensive.  Those who reject the use of masks are saying to those around them “I really do not care if I spread the virus to you.  I do not want to be bothered with a stupid mask!”

The Single Best Weapon to Prevent Covid Spread 

By Dr. Tom Dean 

September 30, 2020

Covid-19 continues to be a major threat across the nation, in South Dakota and in Jerauld County.  For most of the last month, North and South Dakota have been among the states that have had the highest per capita rates of new Covid infections in the US. Within the last 10 days the SD State Health Department has raised the risk of “community spread” for Jerauld County to “substantial” which is the highest risk level.  Community spread means that the virus is moving through the community as opposed to local outbreaks that can be traced to single source.  The health department ranks risks as “none,” “minimal,” “moderate,” and “substantial.”  For several months the Jerauld County risk had been  “none” to “minimal” but then without much warning we saw an outbreak of new cases and the risk level was raised.

How did this happen?  I don’t think we have a specific answer except to say that this is characteristic of this virus.  It moves about  silently and then erupts suddenly. 

All this is hard to keep in perspective. When an outbreak like we had earlier this year seems to settle down the natural assumption is that the danger has passed.  With this virus nothing could be further from the truth.  The virus remains with us and can flare up at any time.  That is why it is so dangerous. 

People who feel fine don’t perceive there is a threat.  I keep hearing “It’s nothing but the flu.”  It is true that for many people the disease causes minimal distress.  A goodly number have no symptoms at all.  Nonetheless, the threat is very real.  Across the country more than 200,000 people have died.  That is between five and  10 times the number of US deaths annually from seasonal flu.  We have had several Covid deaths already in Jerauld County and I fully expect there will be more.

Preventing this requires us to act constantly as though we are in the middle of an outbreak even when we think we are not.  Masks and social distancing are the tools.  They work.  Dr. Robert Redfield, Director of the Center for Disease Control and Prevention (the CDC), one of the true experts of pandemic management,  testified recently before Congress. He held up a face mask and said “this is the single best weapon we have to prevent Covid spread – possibly even better than the vaccines that are coming!”

There can be no stronger recommendations.

A mask-wearing observation  

By Dr. Tom Dean 

September 16, 2020

This week I attended a meeting of about 50 health care providers and medical educators from across the state.  In the invitation to the meeting and on the agenda that was circulated there was no mention of masks.  Nonetheless, at the meeting, virtually  everyone was wearing a mask.  The only exceptions were a couple of people who had face shields.

My take-away from this observation  -  folks who understand and, more importantly, respect  this infection wear masks.

Covid-19 resurgence II  

BY Dr. Tom Dean 

September 9, 2020

A week ago I wrote that the COVID-19 virus had reared its ugly head in South Dakota.  Since then, that head has gotten even uglier.  We have had new outbreaks across the state and for a time,  the per capita  rate of new cases in South Dakota was the highest in the nation.  That rate has receded slightly but it remains one of the highest in the country and is still dramatically higher than it was earlier this year.

At a time when we would hope – and expect – that the disease would be coming under control and that the epidemic would be abating, it has  actually gotten  worse.  How can this be?

The answer is relatively simple.  We have let down our guard and – at least in some areas – ignored the well known precautions – masks, distancing, etc.  During the past few weeks several hundred thousand folks gathered for the  Sturgis Rally,  students returned to college with parties that ensued and in a variety of other social  settings  people came together to celebrate the end of summer.

In so many ways this activity is normal.  We are social beings.  We have many reasons  for partying.  The only problem is that these are not normal times.  They are unlike anything most of us have faced in our lifetimes. They even bear some resemblance to such disruptive strategies as food rationing during WWII.  We have, too often,  refused to acknowledge the seriousness of the infection  and acted as though “all this does not apply to me.”   The virus has  continued to spread and the net  result is the death of nearly  190,000  people with ominous projections for major increases in deaths in coming  months.

Why do we have such a problem?

My perspective is that it stems from a deep public distrust in the usual sources of authority - academic scientists, government officials, public health leaders, etc.  This distrust has been evolving and increasing over a number of years. It certainly preceded the COVID-19 outbreak but has gotten worse since then. The public has been deluged with conflicting information and claims from many different sources.  Political division has added to the confusion. It has made it even harder for the average “man on the street” to know  who or what to believe.   You can’t get on an airplane if you don’t wear a mask (American Airlines has turned away 270 ticketed passengers because they refused to wear a mask) but, nonetheless, 1500 people were allowed to assemble shoulder to shoulder without a mask in sight on the White House lawn to hear the President’s acceptance speech.  

With all these mixed messages, the result,  too often, has been for folks to reject it all.  They chose to go  on as though none of it was really relevant to  them.  Too often  that decision has resulted or will result in deadly consequences.

This virus is not going to suddenly go away.  That is clear.  At the same time we are not destined to live forever under the threats we now face. Vaccines are coming.  If they are developed and used properly, they will convert the COVID-19 threat to the same level as that of tetanus or polio.  These diseases have not gone away but effective vaccines have reduced them, at least in the US, to rare oddities rather than daily hazards.

This optimistic outcome is not a given.  We  hear that  public distrust will lead many  people to refuse to take the vaccine.  We hear that developers are under political pressure to release vaccines before they are fully tested.  Getting the vaccines to the number of people who need them is a formidable logistical challenge. We need to  get enough vaccine distribution in order to establish so-called “herd immunity”.  This means that enough people are immune  from actual infection or from  vaccination  that the spread of a virus is effectively inhibited.  Experts believe that requires around  65% of the population to be immune. 

As I have said repeatedly, we will get through this.  To minimize the cost both in economic and human terms we really must heed the advice of the experts who understand epidemics and really do know how to minimize the pain.  In my view the inconvenience they recommend is a small price to pay.

Where are we?  Where are we headed?

Covid-19 resurgence  

September 2, 2020

By Dr. Tom Dean 

COVID-19 has again reared its ugly head in South Dakota.  After several months in which we saw a steady but relatively low level of new covid infections  there has been a sudden upsurge in the past two weeks.  The average number of new cases per day had been running around 100 but in the last few days that number has reached nearly 400 per day.

What happened?

I do not have a full answer to that question.  It may have something to do with the reopening of school and people congregating for school events.  We know that there were a number of new cases connected with the Sturgis Rally although many of those were out of state visitors and would not be counted in South Dakota statistics.  One of the major factors  probably has been the return of college students to campus and the parties that have followed.

The new cases are not localized in any single area.  The SD state health department lists the threat of “community spread” (meaning the virus is being actively transmitted in that area) as “substantial” in 31 different counties which are spread across the entire state. It is of interest that Iowa and North Dakota have also seen a surge in new infections.

Most likely there is not a single answer to the question of “why now?” What we do know, however, is that the upsurge is real and it does pose a significant threat.  It also reinforces the fact that this virus travels silently and can show up at times and places both unexpected and unexplained.

What to do?

As I have said multiple times, the tools we have are simple and basic but they do work – if we use them.

We hear “I don’t need to wear a mask because I feel fine and the people around me are not sick.”  I understand that reasoning but it is fundamentally not reliable.  As has been said repeatedly, this virus is frequently silent and many of the people that spread it are not aware that they have it.  Many of those who turn up positive cannot figure out where they picked it up.  The only solution in such a situation is for everyone to understand that they could be infected – even though they feel fine – and to proceed as though they carried the virus. This means wearing a mask when around other individuals, “social distancing,”  hand washing, etc.  Doing these things is a nuisance. They  interfere  with our usual routines.  But, they are what prevents the spread of the virus.  A number of  countries around the world uniformly applied these basic tools and have controlled the infection more successfully than we have.   They have proven that they work.

It is troubling that  some folks seem to feel that the request to wear a mask represents some sort of insult.  Even more difficult are those who  see the whole discussion in political terms and feel that the decision about mask wearing – or not wearing – is a political statement.  In my view that is unfortunate  and is a  complete misreading of the situation.  We are all in this together.  We have to protect the guy/gal next to us  even if we are disturbed they support the wrong candidate.  We do that so that we can expect they will do the same and in turn we all will  be protected.  If we are divided we produce the openings the virus needs to attack.  Our experience shows us that is what will happen.

Political conflict and mixed messages from authorities along with our failure to effectively work together have weakened and compromised our response to covid.  That is why with only 5% of the world’s population we have 22% of the world’s covid deaths.  The recent surge of new infections shows that we are not yet in control of this pandemic.

We will win.  We will win quicker and at less human cost if we acknowledge – and use – the simple basic tools we have.

COVID and other diseases  

August 19, 2020

By Dr. Tom Dean 

COVID-19 has come to dominate the news and especially the medical news.  One might think that other problems  like heart disease and cancer have taken a holiday.   In fact, the number of these serious diseases diagnosed in the last several months has actually declined. One major study showed a 51% decline in the number of breast cancer diagnoses between a baseline period before covid and a period in March and April after the pandemic had hit the US.  Similar declines were seen for colorectal and lung cancer.

During the same period cardiac catheterization labs reported substantial declines in the number of patients treated for acute myocardial infarctions (heart attacks).

These data raise serious questions.  Has the number of these other diseases actually declined?  No one really believes that.  More likely,  the onslaught of COVID cases made it more difficult for patients with these other medical problems to get the care they need and, quite possibly, because of fear of covid  patients have chosen to delay seeking care.  We don’t yet know the answers to such questions.  I fear, however,  that when we do get  the answers we will find that important diagnoses were missed and important treatment was delayed.

The more we learn about Covid 19 the more complex it becomes.  In the early stages of the pandemic it seemed that it was a strictly respiratory disease.  That continues to be the dominant clinical presentation – lung inflammation leading to severe breathing difficulties.  We now know, however,  that the infection can lead to a variety of other medical problems.  Kidney failure is common in those who become severely ill.  Blood clots are much more common to the point that most severely ill covid patients have to be treated with blood thinner medications which have their own set of complications.   There are reports and increasing concern about long term complications, especially lung damage but also heart damage in those who recover from the acute infection.

For the most part younger people have less severe problems when they contract covid.  However, there are reports of  myocarditis (heart inflammation) in young athletes infected with covid and we have heard much about a rare but dangerous condition in children known as Multisystem Inflammatory Syndrome (MIS).  This has caused severe illness in young children and even a few deaths.

All this means that  we need to do everything we can to contain the virus and prevent the spread.  At the same time we must not lose sight of the fact that the threat of other serious diseases continues.

A great  way to support the battle against  one of these major threats, cancer, is to support the American Cancer Society.  The Jerauld/Sanborn unit of the American Cancer Society is sponsoring the annual  Relay for Life this week at the City Park in Wessington Springs.  We have a great tradition of supporting Relay for Life.  As with everything else the structure of the program is a little different but it is no less important. Check the details in the True Dakotan.

I’m tired of the coronavirus 

August 12, 2020

By Dr. Tom Dean 

I’m tired of the coronavirus — tired of hearing about it, tired of worrying about it, tired of all the hassles it has caused in our day to day life. It seems that every time we turn around there is some new aspect of the virus that interferes with what I want to do.    I suspect that describes the attitude of many of us.

However, if I were a virus (imagine that if you will) I would probably say “This is great, I’m wearing them  down (meaning all us humans)  and I’ve about got them where I want them. They will soon decide that  the restrictions are not worth the trouble and will let down their guard. At that point I (the virus) can run wild.” 

As far as I know  viruses do not lie around and plot strategy.  If they did I think a scenario like the one above would be quite plausible.  

I have said before it is really  difficult to fight an enemy we cannot see,  cannot hear,  cannot feel – that is, until it hits us.  There is a great temptation to say that all this turmoil is overblown.  All the limitations don’t really apply  to me.

In fact, it is exactly this attitude that has been the single biggest contributor to widespread covid outbreaks we have seen in recent weeks.  On the presidential level, the state level – with a  few exceptions – and all too often on a personal level as well,  we simply have not taken the covid threat as seriously as we should have.

I have frequently brought up the experience of other countries.  Because of the huge variation in the effectiveness of covid control from country to country I think there is much to be learned.  

In South Korea, for instance,  from the very first case they began widespread testing.  As  each positive case was identified they immediately identified the person’s recent contacts.   Contacts were then quarantined for 10 – 14 days.  In effect, they put a fence around the virus – in the terms of some of the experts they “boxed it in”.  The net result has been a dramatic lowering of the risk to their population.  With a total population of over 50 million they have had only 305 deaths.  This  compares    with the US which has a population of 320 million but which has had 162,000 deaths, a death rate more than 80  times higher than in Korea.

Contact tracing and isolation are being used in the US.  However, we were slow to get started, we do not have the organized public health infrastructure which exists in many countries and by the time we got rolling with the process we were confronted with a massive number of cases. 

The bottom line.  The ultimate responsibility for control of covid really  lies with  us.  Hand washing,  avoidance of crowded areas and mask wearing are the tools.  There is abundant evidence they work but only if we – each and every one of us - use them.

Finally a word about masks.  They work to reduce the spread of the virus.  We now know that there is benefit for the wearer as well but especially there is benefit for those around the wearer.  In other words, I wear a mask primarily to protect those around me.  I hope those around me will wear one to protect me

Don't let your guard down 

July 29, 2020

By Dr. Tom Dean 

This week I have a very simple  message.  Don’t let down your guard.

I have said repeatedly – and probably monotonously – we have limited tools to combat and defeat Covid 19.  You all know what they are: aggressive testing, social distancing,  hand washing,  and mask wearing.  

These simple tools work.  However, one of the biggest challenges  we face is maintaining vigilance.  It is hard to fight an enemy we cannot see, cannot feel and cannot hear.  The fact that we do not know where this enemy is represents  the unique and the most dangerous characteristic of this infection.

In South Dakota we have largely been spared the devastating impact of the aggressive “community spread” which was seen in New York and which is now presenting such a threat in Florida, Arizona and Texas.  We had a small outbreak locally early on. There was a significant outbreak at LSI and state wide there was a major outbreak at Smithfield.  All of these have been largely contained.

However - and here is the key issue - the fact that we have  not seen  the  ravaging impact of  “community spread” does not in any way mean that we are immune from that possibility.  In the media we hear most about the terrible situation in the South especially in Florida.  However,  as of  Sunday, July 26, 35 states were reporting increasing numbers of infections.  South Dakota was one of 15 states where the number of new infections was stable and only 2 states were reporting decreasing numbers (data includes the Virgin Islands and Puerto Rico).

Whether we like it or not we are in for a long haul  -  as Gov. Noem has stated “a marathon”.  We have to remember that though we do not have precise numbers probably 80-90% of our population is still susceptible to this infection and it can sneak in when we least expect it.

We can and we will win but we cannot let down our guard.  Wash your hands,  avoid crowds and wear your mask.

 

Why are we arguing about masks?

July 22, 2020

By Dr. Tom Dean 

There is much that is confusing about Covid-19 but one thing that is clear.  Wearing a mask – any kind of mask – helps to reduce the spread of the disease.

The biggest problem I believe is a basic misunderstanding of how masks work.  I believe that if the public  better understood this we would  see less resistance to their use.

In reality we have only a few reliable  tools to fight Covid.  More weapons are in the works but for now social distancing,  isolating positive  contacts and cases, avoiding crowds and wearing facial coverings are what we have.  These may seem simplistic and perhaps even a little primitive.  They are, however, what we have and, more importantly, they really do work.

Countries as diverse as Germany, South Korea and New Zealand  using these simple tactics have reduced their numbers of new Covid cases to a few hundred per day (New Zealand has even claimed to have eliminated the virus).   In the meantime those numbers in the US have shot up into the tens of thousands (most recently over 70,000).  Likewise their numbers of deaths have remained in the low hundreds while the number of deaths in the US is over 140,000 and rising rapidly.  With only 5% of the world’s population we have 24% of the world’s Covid deaths.

In reality,  control of this epidemic is up to us – each one of us.  The scientists and medical experts can tell us what the virus does to our bodies and how it  spreads.  However, given the tools we have, only we as individuals can actually do what is needed to contain it.

None of us like to be told we have to do something – especially something that does not seem to benefit us directly.  The main benefit of wearing a mask is to prevent the spread of virus carrying droplets from someone with the infection to those around them.  If we always knew who was carrying the virus we could easily identify who needed to wear the mask.  Unfortunately – and this is vitally important – this virus, more than any other  serious disease,  infects large numbers of people who have no symptoms.  They are totally unaware they are infected and yet can spread the disease widely.

This is exactly what has happened in the south and west – especially Arizona, Texas and Florida.  Folks who had been cooped up with “stay at home” orders rushed out to be with their friends, did not appreciate the importance of the cautionary guidelines and, inadvertently, caused massive increases in infections.  Death rates which had been trending down have now gone up and are continuing to rise.

Widespread use of masks when folks are in a public place, even if they  feel perfectly fine, will reduce the spread of the disease.  This is a fact.  There was some uncertainty about this in the beginning but it has now been proven.  In addition, we now know that the wearer of the mask does get some protection from the virus even if this is not the main benefit.

Those who  argue that pushing for wide spread mask use violates some abstract personal right are, in my view, completely missing the point.  As I have said several times in these columns we are in a war.  Right now we are losing.  Wars require sacrifices from us all.  We will win but we will win sooner and with less cost if we all are willing to make some fairly simple sacrifices.  Wearing masks when we are in public is the number one request on that list.

COVID-19 – where do we stand?

July 15, 2020

BY DR. TOM DEAN  

I’m concerned.   No, I’m actually quite worried.  Several weeks ago I wrote that things were confusing – some things better and some things not so good.  This week the situation is clearer and the news is virtually all bad.  

We have seen massive increases in numbers of infections, major increases in hospitalizations and ICU admissions and a turn around in the death rate numbers.  Mortality rates which had gradually been declining  have now begun to increase.  

To make matters worse we are seeing a repeat of the same problems we saw back in April – not enough protective equipment for health care workers,  not enough testing capability to determine who has the virus and who does not and unacceptable delays in getting back test results – sometimes more than a week.

This past week we heard, on an almost daily basis, that the number of new infections had broken previous daily records. It reached a level of more than 60,000 per day compared to a previous peak of just short of 32,000 in mid April.  At this point, the US, with about 5 % of the world’s population, now has had 24% of worldwide COVID 19 deaths.

All this is happening  while other countries around the world have seen their numbers steadily drop and have not seen the sudden surge seen in the US.  Germany for instance hit a peak of new infections on April 5 with 5600 new cases per day.  Their most recent number was 351 cases per day.   In Canada the peak was at 1623 new cases per day on May 2 but only 290 cases per day in the most recent report.  Some other countries such as Brazil and South Africa  have seen an increase in cases but no country has seen the massive surge seen recently in the US.

A very interesting natural experiment has developed in Scandinavia.  When the danger of the COVID 19 pandemic became apparent Norway and Denmark took the common “lockdown” approach of closing schools, telling residents to stay at home, etc.  Sweden on the other hand refused this approach.  Schools remained open, bars and restaurants did not close and residents were urged to go about their business with only minimal restriction. The reasoning behind this approach was that they would see more early infections but that those infections would provide immunity and in the long run the country would be better off. Unfortunately that reasoning proved faulty. Now, three months later the overall death rate in Sweden is twelve times higher than Norway and six times higher than Denmark.  Keeping the Swedish economy “open” has not protected the country from a serious economic downturn.  The central bank of Sweden has projected a 4.5% contraction which is actually greater than that projected for Denmark and Norway.  In short, by opting not to restrict person to person contact, Sweden suffered a substantially higher death rate than its neighbors and did not reap the economic benefits it expected.  

What does all this mean?

As has been said many times previously, we are in a war.  Unfortunately, leaders in the US have seriously underestimated this enemy.  We are now paying the price of that misjudgment.  When new infections and deaths declined after the initial surge in March and April we mistakenly took that to mean that the battle was won.  Instead of building up testing capacity and laying in supplies of protective equipment (so called  PPE)  the emphasis was on steps to “reopen” the economy. In many locations, as restrictions were relaxed, even basic precautions were not followed.  As has unfortunately been demonstrated so well in the example from Sweden, an economy cannot recover until the virus is truly under control.

In South Dakota we have not seen the massive surge of new infections seen in other areas.  Nonetheless, the virus is still with us and will attack if we let down our guard. It is true that younger people usually tolerate the infection better than older folks but just this past week in South Dakota there were two deaths in patients in their 30’s. Even among those who survive a number will be left with long-term lung, heart and kidney damage.  We all need to be cautious.

This is a war and wars require sacrifices.  Mask wearing, social distancing and minimizing contact with large groups are still the best tools we have to fight this enemy.  We will win but we will win sooner if we work together and are all willing to make these relatively simple sacrifices.

Are we winning or losing? 

July 1, 2020

BY DR. TOM DEAN 

The war with Covid 19 – are we winning or losing?

The daily news reports relating to COVID-19 and its impact are, if nothing else, confusing.  Numbers of deaths are down, numbers of infections are up.  Some states have “reopened” and others, having “reopened,” are now beginning to close down.  All the public health experts say we all should wear masks and avoid large indoor gatherings.  The President and his supporters do exactly the opposite.

Little wonder the public is confused.

Much of the confusion comes from the fact that we are in uncharted territory.  We as a nation have never, or at least not for a very long time, confronted a challenge as perplexing as Covid 19.  The fact that it is entirely asymptomatic for many of those who are  infected means that it can spread undetected through large parts of the population only to flare up and reek death and destruction when the conditions are favorable.  This is what we are now seeing in the south and west - massive increases in new infections as people ignore basic public health precautions and flock to social gathering spots.

What have we missed?

Somehow the image has been transmitted that the young are invulnerable.  It is true that the vast majority of the deaths are in the elderly – especially those over 80.  However, in S.D. 225 people under the age of 50 have been hospitalized and 10 of those have died including 4 in the 20 – 40 age group.  These are not trivial numbers.

From a policy perspective we seem to think that our only options are to be totally closed down to prevent infection spread or we eliminate all restrictions  in order to reduce the negative economic impact.  Again,  this is a serious distortion of the actual situation.  The bitter irony is that rushing to “reopen” before effective precautions are in place can result in a relapse of infections.  This  actually prolongs and increases rather than reduces  the economic damage.  We are seeing exactly this in the south.  Governors of Texas and Florida, in the face of massive increases in infections, are re-imposing  restrictions that had been relaxed.

We hear claims that the increased number of cases is due to more testing, not an increase in infections.  While that could happen, in Texas, Arizona, Florida and California, hospitalizations (new infections) are increasing and ICU’s are nearing or at capacity.  Death rates are still much lower than they were in April.  However, death rates lag behind infection rates by 2 -3 weeks.  The recent dramatic spike in infections will almost certainly lead to more deaths in the days and weeks to come.

So……are we winning or losing?  Right now I would submit that we are losing ground.  After the crisis in New York calmed down  we were lulled into thinking that we had this virus under control.  As the folks in the south are now finding,  that conclusion was sadly very wrong.

We are painfully being reminded that  this virus is a cunning and devious enemy.  It will lie silently in wait until the conditions are favorable and then will strike with a vengeance.  

We will win.  But, if we are to minimize the pain, we need to set aside the partisan bickering and trust the guidance of the scientists.  We will eventually have a vaccine – or multiple vaccines - and will be able to establish a level of immunity in the population which will allow social gatherings and freer movement.  We need to remember though that even if a vaccine becomes available early next year, vaccinating  320 million people (or even 60% of that which is what the experts say we need if we are to prevent more spread of infection) will not happen overnight.

Again.  We will win but this is a threat like none we have faced before.  Success will come sooner if we pull together, if we respect the precautions the experts have put forth and if  we accept that we all need to make some sacrifices if we are to protect ourselves and those around us.

An interesting aside.  Rep. Liz Cheney [(R)Wyoming], daughter of the former Vice President, recently circulated a picture of her father wearing a mask with the caption “Real men wear masks!”  I say “right on!” 

What about masks?

June 24, 2020

BY DR. TOM DEAN 

I have written about this issue before but it keeps popping up.  Actually,  it seems to be more of an issue now than it was several months ago.

The bottom line is that the main value of wearing a mask is to prevent the wearer from inadvertently spreading the COVID-19 virus that they may be carrying and yet have no awareness that they are infected.  However, that is not the only benefit.  Depending on the type of mask used, there will be some benefit to the wearer as well.

Many will argue that they feel fine and therefore could not be spreading the infection.  They are WRONG.  A large portion of those infected with COVID-19 have no symptoms at all but can still spread the virus. That is a major reason why this infection is so difficult to deal with. It spreads when we do not even know it is there.

It takes 5-7 days after a person contracts the virus before they become ill – if they are even going to become ill.  During those 5-7 days they may well feel just fine. Nonetheless, the virus is in their system and it can be passed on to others before the individual knows anything about it.

Much attention has been paid to the need to clean surfaces with which we come  in contact.  That is important but the reality is that far and away the most common manner of spread of this infection is person to person contact – coughing, sneezing, shouting or even just talking.

The main reason for wearing a mask is to prevent virus laden droplets expelled by the wearer from reaching people who are nearby. Secondarily, masks may give some protection to the wearer by trapping virus containing droplets in the air from being inhaled by the wearer.

Homemade masks do work.  They need to cover the nose and the mouth and they need to fit tight enough to reduce the amount of air that can move around the sides and top.  More layers of fabric are better and some fabrics are more effective than others.   Details on these specifics are available on the CDC website and multiple other sources.

It is unfortunate that so many people seem to feel that asking them to wear a mask is some sort of intrusion or violation of their individual rights. The rugged individualism which has contributed so much to the success of our country is in this case actually a detriment. 

In responding to this pandemic, almost more than any other recent challenge, we need to take care of each other.

In deciding about wearing a mask the basic question one needs to answer is: “Do I care enough about the safety of those around me that I am willing to put up with the minor inconvenience of wearing a mask?”  I would hope the answer is “yes.”

With Liberty and Justice for All        

June 10, 2020

BY DR. TOM DEAN 

The death of George Floyd at the hands of a Minneapolis police officer has moved the fight against COVID-19 to a new and much more complex level.  Not only do we have a battle against a vicious infection but the events of the past two weeks have shown that we have both  a health care crisis and a serious problem with the ways in which the laws of our nation are enforced.  

The  depth and intensity of the protests, the rapidity of their onset and the widespread geographic distribution of the responses shows that we are dealing with concerns  which go well beyond the offenses of cops in Minneapolis. Nearly two weeks after the death of Mr. Floyd massive – mostly peaceful – demonstrations continue in cities across the country.

These crises are connected. Police misconduct did not impact the spread of the virus and COVID-19 was not a contributor to the death of Mr. Floyd.  However, both  crises are painful reminders that we as a society have not lived up to the simple but inspiring words of our pledge of allegiance “with liberty and justice for all.”

What do I mean?

With regard to COVID, the situation is mixed.  The rate of new cases has declined in 19 states (including SD), stayed stable in 13 states but is increasing in  21 states (total includes Washington DC, Puerto Rico and Guam).  The public seems to be tiring of social distancing and mask wearing is variable. These observations along with the “reopening” of the economy and the large crowds of protesters we have seen across the country make it  almost certain that we will see increased numbers of COVID cases.  Don’t get me wrong.  We need to reopen the economy – for both economic and mental health reasons.  However, doing so carries risks and doing it safely requires caution.

How does this relate to racism and racial inequity?  

There are many  examples of how minority groups have suffered disproportionately in this pandemic. In New York City the death rate for black patients from COVID was 92 per 100,000 population compared to a rate of 45 for  white patients. Comparable numbers for Hispanic patients were 74 and for Asian patients 34.  Similar data has been reported from a number of other communities.  There are many  reasons for these differences.  Some  we understand and some we do not.  The point is that  these discrepancies, coupled with a history of racial injustice from law enforcement give us a better  understanding of the intensity and widespread nature of the suffering endured by many minority communities.

What to do?

Concerning COVID  we are on track with regard to vaccine development and therapeutics.  Nonetheless, we can’t lose sight of the fact that until we have a vaccine, social distancing,  masking and wide spread testing remain our best weapons to reduce transmission. These require compromise and sacrifice but they work. 

Abusive behavior from law enforcement is much more complex.  I firmly believe that most law enforcement officers are committed professionals  who are trust worthy and dedicated to improving the communities they serve.  They want what  we all want, stability, fairness and protection for the citizens in need.  I was especially moved by a film clip of the sheriff of Flint, Michigan, a white cop in a community that has suffered much at the hands of irresponsible city leadership.  Sheriff Swenson went to supervise a protest, was impressed by the sincerity of the protesters, took off his helmet, set aside his baton and joined the marchers.  He took a real risk and by all accounts it paid off big time in good will.

Effective policing, especially in densely populated urban areas, can be immensely challenging.  There can be real danger to both residents and to officers.  Split second decisions may be called for. Inevitably mistakes will be made.  Where we seem to fall short is in our ability to adjudicate  disputes in ways that are objective and fair to both the public and the police.  Correction will require broad input.  To be most effective major  input should come from the police community itself. Bad cops are a threat to good cops just as they are to the community at large.

At the time he died, George Floyd presented absolutely no threat to the police.  He was unarmed, alone, hand cuffed and on the ground with several officers around  him.  This was a gruesome event with images which will live on.  We can only hope that this trauma will motivate the change we need to move to that ideal we treasure, “liberty and justice for all.”

Mask-wearing an effective first step in defeating a fierce enemy  

June 3, 2020

BY DR. TOM DEAN 

Why do we need to wear a mask?

Who should wear a mask?

Recommendations have actually gotten simpler.  Everyone, yes everyone, who goes out of their home and will meet  other people should wear facial covering – a mask of some type.

The reality of this infection is that many people can become infected, feel just fine and yet still spread the virus.  If those carriers without symptoms wear a mask the chances that they will transmit the virus to those they meet  is much reduced.

But there is more to it than that.  Recent studies show that even though cloth masks will not block the virus they can block droplets spread by infected persons when they cough or sneeze. Thus, they do provide some, admittedly limited, protection for the wearer.  Another issue, though it may sound a bit silly, is that masks prevent the wearer from touching his/her face. Virus on the skin is not dangerous.  If it gets to the nose or mouth it will invade the body.

Finally, I believe wearing a mask makes a statement.  It sends a message.  It says “I care about the welfare of those I am about to meet.   I am willing to put up with the inconvenience and, yes, a funny appearance, to reduce the chance of spread of this vicious virus.”  Personally, I see that as a sign of maturity and strength, not weakness.

I think it is deeply unfortunate that the decision to wear, or not wear, a mask has come to be   seen by some as a political statement.  Going bare-faced is apparently seen as some kind of  individual right not to be infringed upon by some elite, far away medical expert.  In my view this is not a sign of strength. It is the same kind of faulty reasoning which leads adolescents to think they can drink a six pack of beer and then drive 100 MPH.  Sometimes they get away with it and all too often they do not.

We are in a war. The enemy is no less vicious and no less deceitful than any we have faced in the shooting wars we have fought over the last century.  We are all  in this together and the extent to which we win or lose is largely based on how willing we are to make some sacrifices and to do what we can to protect our neighbor.

The good news, and there is some good news, is that mask wearing, social distancing and quarantines do work.  The most dramatic example of this is in South Korea.  The first COVID-19 death in South Korea occurred at the same time as the first COVID death in the US.  The Koreans began immediately a program of aggressive testing, mask wearing and quarantine of contacts.  As of a week ago they had had only 266 deaths.  South Korea is a much smaller country than the US but if we translate their death rate to a population the size of the US  (approx. 329,000,000) we still only get a total of about 1700 deaths.  This at a time when the total death count in the US just passed 100,000 — 1700 vs 100,000!  No other country has been able to match the performance of the Koreans.  However,  if the death rate in Germany was applied to a population the size of US there would be 32,800 deaths, Canada  would  have 56,000 and Japan would only have 2115.  All these numbers compared with the 100,000 plus in the US.  

I believe we are in for a long battle against a fierce  enemy that hides and strikes without warning.  We are all in this together and we need to look out for each other.  Wearing a mask is an easy and effective first step.

Viruses, vaccines and challenges     

May 27, 2020

BY DR. TOM DEAN 

What is a virus?

We hear so much about viruses but do we really know what  they are?  I suspect many folks have never actually  stopped to consider that question.

Viruses are incomplete organisms, actually better referred to as “particles”.  In fact,  it is not even really appropriate to use the term “organism” since viruses by themselves have no metabolic machinery, cannot produce proteins or any other product and cannot even reproduce on their own.  If that is the case then how do they cause all the trouble they do?

A  virus particle is a piece of genetic material (DNA or RNA) with a protein coat and sometimes an “envelope” around that.  By itself it is completely inert.  But…they have the ability to invade a living cell, take over the metabolic machinery of that cell and force it to do all sorts of things, most of them undesirable.  They are essentially kidnappers!

What is a vaccine?

Vaccines are compounds which, when introduced into the body, essentially “fool” the body into believing an intruder is present and that a defense needs to be launched.  That means that the body will mobilize the immune system which produces antibodies (usually proteins which attack the intruder and inactivate it) and/or  so called “killer” cells, usually lymphocytes, which strike the virus directly and destroy it.  Once the body has gone through this process it will “remember” this intruder and the next time the trespasser shows up there will be a more rapid and complete attack.  

Why is vaccine development so hard?

The challenge  is to find something that will tell the body that an invader is present and that an immune response is required.  If the immune system has been “programmed” by a vaccine  ahead of time to alert it that this “particle” is a bad guy it will respond quickly and kill the invader before it has a chance to get established and cause disease.

To  stimulate this desired response, vaccine developers have used many different approaches. They have used actual viruses that have been killed by chemical exposure – such as to formaldehyde (the Salk polio vaccine is an example).  In some situations, living viruses are used that have been genetically altered so they no longer produce disease (the Sabin oral polio vaccine is an example).  Sometimes researchers  have been able to take part of the virus such as the protein coat,  inject that and get an immune response that attacks the whole virus.

On the surface this sounds basically pretty simple and straight forward.  It is not!  The human immune system is  exceedingly complex and the responses it produces are not always predictable. It does a very long list of good things such as fight off common infections and it is probably our number one defense against cancer. However, it can also do very bad things. There are a number of so called “autoimmune” diseases such as lupus and rheumatoid arthritis in which the immune system attacks normal tissue often with disastrous results.  

Additional difficulties are that some viruses mutate frequently, meaning that their genetic makeup actually changes.  The influenza virus is famous for this which is the reason that a new flu vaccine has to be produced each year.  Furthermore, just because a vaccine induces an antibody response it does not mean that it will prevent the disease in question.  That has to be proven separately.

With regard to COVID-19 there are, as I understand it, more than  50 different potential vaccines in various stages of development and testing around the world. Developers  have used all the approaches described above as well as some new ones.  Each product must demonstrate: 1) is it safe, 2) does it provoke an adequate immune response and 3) does that immune response  actually prevent disease when  given to large numbers of people without unexpected and unacceptable side effects.  All three of these stages represent  vitally important questions which take time and can have life or death consequences. This is not a place to cut corners.  In the past that has been done and there have been some disastrous consequences.

We are making progress.  Things will get better.  As I have said before, there is light at the end of the tunnel but we are still in the tunnel!

To open or not to open?

May 20, 2020

BY DR. TOM DEAN 

Should we relax/remove  the restrictions on public movement and commerce or should we continue to encourage, even require, people to stay at home, “shelter in place,” etc.  in hopes of  limiting the spread of the COVID virus and reducing the risk of disease and death?

As is so often the case when a decision is laid out in terms like this it is actually a gross over simplification. I would argue that it is not a question of “either/or” but rather “both/and.”  Given the well documented disastrous  impact that COVID-19  has had on our economy we  will all benefit from a return to economic growth.  At the same time, the virus is still with us and will attack if we don’t proceed with caution.

All the indications are that this virus will be with us for a long time to come. So, even though we  have not defeated the virus, we can still outsmart it.  Gradually a larger portion of the population will have recovered from the infection and presumably will be immune.   As that number increases we will move toward a situation known as  “herd immunity.”  This means that spread of the infection is restricted because more and more of the folks an infected person contacts will already be  immune and not susceptible to infection.  However, for herd immunity to be fully effective the portion of the population with immunity needs to be in the range of 60 – 80%.  Right now estimates are that the rate of immunity is in the range of 5 – 10 % so we have a long way to go.  However, if/when a vaccine becomes available that number should increase fairly rapidly.

Even without that degree of protection we do not need to live in a cave.  There is much that both individuals and merchants can do to reduce the risk of transmission.  Simple cloth masks reduce the likelihood of viral spread as do transparent barriers between sales people and customers.  Frequent hand washing, liberal use of hand sanitizers and continued attention to “social distancing” are all effective strategies.  Inconvenient?  Yes, but smart, and, as I said,  if we are not in a position to kill the virus we do have ways to outsmart it.

In the demonstrations we see around the country objecting to social isolation policies, we hear that such policies take away our basic rights.  I understand that.  However, I would counter that if we are to live in an organized society we have a simple responsibility, within reason, not to take undue risks ourselves or to subject  our fellow citizens to unnecessary  risk.  This is similar, I would argue, to speed limits on highways. I may be convinced that I can safely drive 100 MPH but our society has decided that is not the case and that my right to drive fast is less important than my neighbors right to be protected from hazardous driving. (As an aside, this is not a new debate.  I remember vividly how agitated and angry my father was  60+ years ago when he learned that the state was going to require everyone  to have a drivers license. From his perspective that was a fundamental intrusion into his rights as a citizen and he was furious!)

It is deeply unfortunate that decisions such as this have more and more become politicized.  Public health experts like Dr. Anthony Fauci (who, by the way, has served six different presidents from both parties) who have been called upon to offer independent professional opinions have been demonized if they offered opinions that differed with the administration.   Some have even had their personal safety threatened.  We will never be able to come to wise decisions if we are not able to collect honest evaluations from all perspectives.

The threat posed by COVID-19 represents a once in a lifetime disaster. The unique characteristics of this virus  present a menace greater than any we have dealt with in recent memory.  Dealing with a threat of this magnitude demands sacrifice on the part of everyone.  This may well mean that some individual rights are constrained in order to reduce the risk to those around them.  Achieving a proper and acceptable balance between individual and population rights requires constant  juggling and reevaluation with a continuing commitment to fairness and honesty.  To get through this we need to, as best we can, set aside partisan bickering and go with policies based on science and objective facts.  If we do less than this, in the end, we will all be worse  off.

What’s coming next? What are we to prepare for?   

May 6, 2020

BY DR. TOM DEAN 

Are we prepared for what comes next?

That would seem to be a sensible  question.  However, being prepared means that we actually know what was coming next.  What is it we are to prepare for?

The problem is that we have two conflicting visions about how to proceed.  If we make the wrong decision in either direction there are ominous consequences.  

Are we moving out of a “lock down” phase into a time of economic reawakening and rebuilding with a gradual – or if you believe the President — a not so gradual return to life as we knew it before COVID-19 came to dominate our lives?  Or, are we in a brief period of respite where relaxation of social distancing precautions – letting down our guard if you will – will allow a dangerous second wave of infection?  Economists tell us that we are facing economic disruption of a magnitude which rivals that of the Great Depression and the sooner we get the economy moving the better are our chances of lessening that impact.  On the other hand, relaxing safeguards too soon raises the risk of a resurgence of infection every bit as bad as the first wave.

I don’t have a confident answer. However, my bias is that  we are facing a challenge akin to a forest fire.  Firefighters know all too well that even after the main blaze is out, if they go off and assume the battle is won,  previously hidden “hot spots” will flare and could become every bit as threatening as the original blaze.

Is there a middle ground?  I think there is.  Even though many states have ignored them – even the President himself – the  White House guidelines provide some sensible direction.  Before economic “reopening” there should be at least a 14 day period of declining infections and hospitals need to have moved beyond the crisis phase of overloaded ICU’s and exhausted staffs.

Moving forward in a cautious and safe manner requires knowing where we are in relation to the virus. This depends on testing – widespread and easily available testing - that will allow face-to-face meetings and discussions to safely take place, that will let employers know that their employees are not spreading the virus and that will allow family members to know they are not going to carry the virus to frail relatives.  We are closer to that goal and we need to keep pushing.

What have we learned?  National security threats come from many directions.  As a nation we were completely unprepared for an attack such as this.  National security attention had focused on military issues and our public health preparedness had been allowed to deteriorate. This problem was further exacerbated by short term thinking and political division.  

We will get through this and we will survive. Hopefully we will be both stronger and smarter.  But, we are in for a long haul. In spite of all  we hear about new drugs and stepped-up vaccine development, there is no quick fix.  Gov. Noem has described it well when she repeatedly reminds us “this is a marathon, not a sprint.”

Where do we stand? 

April 29, 2020

BY DR. TOM DEAN 

Where are  we?  Or, more importantly, where are we headed?

This week we heard much about “reopening,” that is loosening the “stay at home,” “shelter in place” directives which have been issued in many states.  Businesses are beginning to open their doors and to return to doing the things they did before the onslaught of COVID-19 —  though clearly with some new precautions in place.

Reopening at this time is highly controversial.  It represents a clash between the forces pushing for a revival of a severely damaged economy and those who argue that this move is coming too soon.  They fear it  carries  a major risk of a second wave of infection and a serious risk of an uptick in illness and death.

Undoubtedly, there is no single right answer. Situations regarding the COVID-19 infection vary widely across the country.  In some densely populated areas it is awfully difficult to increase economic activity without also increasing person to person contact which we know is the way this highly infectious virus spreads.  In more sparsely populated areas like ours, it is easier.

The basic question is where do we stand in this war against COVID-19? For all the progress that has been made all the indications are that we are still in the early stages.  Let’s look at the numbers.  They are disturbing.  Epidemiologists have estimated that somewhere around 50% of the population will  eventually be infected.  The US population is approximately 320 million so we are looking at 160 million infections. Death rates have ranged from 0.5% to 3-4%.  If we take the lowest and most optimistic death rate number of 0.5% and apply it to 160 million people we get  800,000 projected deaths!  We are now at  roughly 55,000 deaths nationwide. That is a gigantic gap!  Do I really think we are going to have  800,000 deaths?   No, I do not, but these projections come from our actual experience dealing with COVID-19 and from the behavior of previous epidemic infections. They cannot be cast aside lightly.

The danger I see is that we will misinterpret our success at “flattening the curve” as success in eliminating the virus.  Flattening the curve spreads out the incidence of new infections over time to allow the medical system to keep up.  It does nothing to eliminate or even reduce the number of viruses that are floating around.  Until we find drugs that kill the virus or an effective vaccine we are left with preventing person to person transmission as our only reliable strategy in this war. That means continuation of some form of social distancing.

As opposed to the test for the virus which we have heard so much about, the role of antibody testing is receiving more attention.  After one has had the infection the body produces antibodies to the virus.  We believe – though it has not been proven -  that the presence of those antibodies means that one will not be susceptible to the virus again.

The public needs to be aware of  the fact that there are on the market a number of antibody tests which have never been validated by the FDA.  Some of these have been shown to give highly unreliable results.  Ordinarily tests such as these would never be allowed to be marketed without  first demonstrating to the FDA that they gave accurate results.  In this case, apparently,  the administration pressured the FDA to loosen those restrictions.  In my view that was a serious mistake in that a test giving the wrong result may well be worse than no test at all.  If someone took the test and got a false positive result (suggesting  they had antibodies to the infection when they did not) they would think they were immune to the virus and would likely set aside the usual precautions.  They risk  becoming infected with the virus they could have avoided.  The tests that have been validated by the FDA are labeled as such and, in my view, no one should use a test without that assurance.

So where are we?  The beginning of the end or the end of the beginning?  I am afraid it is the latter.  One commentator summed it up well when he said “there is light at the end of the tunnel BUT we are still in the tunnel.

Be careful and be well.

COVID-19 update: Entering a new phase 

April 22, 2020

BY DR. TOM DEAN 

It appears that we are entering a new phase in the COVID-19 war.  We have proven that social distancing works.  We have shown that it  reduces  the number of new infections and that it can “flatten the curve.”  To some degree and in some areas, there is evidence that we are gaining the “upper hand” in what is clearly a vicious and costly battle.  As we enter this new phase the question is “When will it be safe to back off some of the restrictions?  When can we return to some semblance of life as we knew it before COVID-19?”  

As much as we want to get away from the restrictions and as much as we need to  begin  to repair  the damage done to our economy,  we need to be aware of new and sobering reports about second waves of infection.  Such reports  are  coming mostly  from Asian countries like South Korea, Japan and Singapore.  These are the countries who attacked the disease early and  aggressively with wide spread testing, contact tracing and quarantine of positive cases.  Their death rates have been relatively  low and it seemed they had the virus under control.  Nonetheless, Singapore, reputed to have one of the most effective public health systems in the world, has just seen a serious uptick in the number of new cases. On Hokkaido, a major Japanese island, the number of new cases was way down and kids had begun to return to school.  However, in the last several weeks the number of new cases jumped up and authorities have just issued a “state of emergency” for the second time.

COVID-19 is clearly a “stealth” infection.  It has a very high rate of asymptomatic carriers.  Estimates are that as high as 80% of infected people are unaware they have the virus. However, they are still able to  transmit it.   Furthermore,  the virus is even more infectious than we first believed. This means that  person to person spread happens more easily and more effectively than was first thought.

Does this mean that we are forever stuck with so called “social distancing?”  Certainly not, but it does mean that we have to be very careful and we have to be smart.  I fear that the demonstrations we are now seeing demanding immediate relaxation of social distancing, etc. are short sighted and may well lead to new outbreaks of infection and deaths that did not need to happen.

What protections should we have in place before we move to the next phase – that of relaxation of restrictions?  If we are to be able to safely return to a more open and normal way of life it seems to me we need three things; 1) widespread and easily accessible testing – both viral testing and antibody testing - so we know where the virus is and where it is not;  2) medical treatments that actually fight the infection in the same way that antibiotics combat many forms of pneumonia and 3) an effective vaccine.  We are not likely to have all three of these in place any time soon but it does seem likely that the first two could be  obtainable within a few months. 

On a slightly different topic, it has been asked why don’t we know more about what drugs actually offer help in COVID-19 cases.  The answer is that measuring the effectiveness of a drug is a more complex process than most people appreciate.  One would think that if a patient with a disease was given a drug and then got better that would show that the drug was effective.  Unfortunately, such conclusions can be very misleading.

 The only way to know if the introduction of a drug is a benefit is to compare the outcome of a disease in a group of patients who got the drug with a similar group of patients with the same disease who did not get the drug – a so called controlled trial.  

One of the tragic examples of the harm that can occur if objective trials are not completed happened a number of years ago.  There was an anecdotal  report that women with advanced breast cancer benefited from bone marrow transplants.  Subsequently, quite a number of women with a very bad disease underwent  bone marrow transplants - a very traumatic and risky treatment - before leaders  had the courage to insist on a controlled trial.  When the trial was done it showed no benefit and bone marrow transplants for breast cancer were discontinued.

Another source of confusion arises when we hear that a particular drug is not FDA “approved” for a particular disease but is nonetheless being used in that situation.  This does not mean that the use of the drug is wrong.  It simply means that the company producing the drug has not asked the FDA to approve that particular indication even though there may be good evidence to support such use. 

We are making progress on all these fronts.  We will get through this and I predict we as a society will be stronger because of it.

For guidance during uncertainty, look to previous generations     

April 15, 2020

BY DR. TOM DEAN 

So, what is the latest in this whole COVID-19 turmoil?  We hear the epidemic  is leveling off – we have flattened the curve.  We hear that the number of deaths may end up being well below the original 100,000 to 200,000 that was projected. 

Obviously this is very good news but  what does it actually  mean? Have we won the battle?  The reality is that even with these encouraging reports thousands of people are still falling ill each day and many are dying – just not quite as many as have in the past.  The virus is still out there, is wide spread and most of the population is still susceptible. The prevalence of the infection varies greatly from one area to the next.  Along with that, projected peak infection rates vary widely.  Projected peak in Texas is still several weeks away and in South Dakota the projected peak is well over a month away.  These projections may or may not be accurate but they were developed by careful scientists and deserve our serious attention.  We need to proceed cautiously.

President Trump is clearly anxious to back off on the restrictions and “open up the economy.”  That is understandable.  This disease and the economic destruction it has  caused  have produced  a truly devastating  impact on our economy.   The sooner we can get people out on the streets, spending money,  going to bars and restaurants and planning  vacations, the sooner we will be able to reduce the economic bleeding.

BUT,  we have learned that social distancing works and, if we let up too soon, history tells us that we will almost certainly see a second wave of infection. This  would set us back even farther.  It would result in deaths that did not need to happen and even more economic destruction.

How do we decide?  It will be a judgment call.  There are no fixed rules.  I believe we need to rely on the wisdom of folks like Dr. Fauci and Dr. Birx and the scientists they work with.  All  have studied worldwide epidemics for decades.  They know the history  and have seen both good outcomes and bad.

What about hydroxychloroquine?  This is an old drug which has been widely used to treat malaria and a number of autoimmune diseases like lupus. It is relatively safe and has shown some promise in fighting COVID-19 in the test tube.  So why not give it to everyone?  First of all we do not  know if it works in a clinical  setting.  Secondly, it does have side effects.  Among other risks, it has the potential to damage vision.  Furthermore, it can cause  a  rare but life threatening heart rhythm disturbance known as torsades. This can be avoided if screened for but will happen if the drug  is not used carefully.  Already there are reports of several deaths from the drug in France.  More directly to the point there is a new, but small,  controlled study from China in which one group of COVID-19 patients received hydroxychloroquine and a similar group received usual  care.  There was no difference in the outcomes between the two groups – no benefit from  hydroxychloroquine.

All this uncertainty and fear gives us some better appreciation of what previous generations lived through during the great depression of the 30’s or the struggles, the stress and the deprivation of WWII.  They survived and even came out stronger.  We can do the same.

Where are we in this fight? 

April 8, 2020

BY DR. TOM DEAN 

The disruption in society and in our economy caused by the COVID-19 pandemic is like nothing any of us have ever experienced.  The President says this is war time and he is clearly correct.  History tells us that war time, at least on the scale of the two World Wars our country fought, called for  major sacrifices throughout society. Though the specifics are different, the impact, the disruption and, yes, the pain it has produced is not all that  different.

So where are we in this fight?  Unfortunately,  indications are that we, especially those of us in areas that have not yet been hit hard, are still in the early stages.  That means that the battle, and the sacrifices which go with it, are likely to go on for a while.  At this point our only weapon against the virus is “social distancing” (actually, “physical” distancing is probably a better term) to slow the spread – slow it to a level where our health care system has a chance to effectively deal with the victims.  Gov. Noem, who has been doing a good job of getting the news, both good and bad, out to the public, has reported that current prediction models indicate that in SD we may not see the peak number of infections for another six to eight weeks. That is not what any of us want to hear.  However, as Dr. Tony Fauci, the acknowledged expert in this area, has said “we do not set the schedule, the virus sets the schedule!”

So, what happens when the rate of infection begins to go down? Does that mean that we are “home free,” that we can ditch the physical distancing precautions and go back to our usual routines?    Regrettably, NO!  The number of infections may go down but the virus will still be around and will be as dangerous as ever to those who are not immune. The need for precautions will still be there.

Is there no good news? It may well seem that way.  However, as time goes on it is likely that we will develop more and better ways to combat this enemy.  Better and more available testing will allow us to identify cases earlier and target  our isolation procedures more effectively.  Many drugs are now being tested and it seems highly probable that some of these will prove effective which means we will have ways not just to avoid the virus but to actually kill it.  The FDA has just approved an antibody test by which we can tell who  already has immunity to the virus. Those who have such antibodies could presumably – we don’t have proof of this yet – go back to work without fear of infection.  Finally, probably the best hope for full control of this epidemic is the development of a vaccine.  Although early trials of a number of  vaccines are now being run, the availability of a fully effective and safe vaccine is likely many months away.

A concept which will become more relevant as time goes on is what is known as “herd immunity.”  Herd immunity describes the situation when a large portion of a  population becomes immune to a contagious infection.  When that portion is large enough even those members who are not immune have some degree of protection since infectious agents do not spread as easily.  How high does the immune portion need to be to provide significant protection for the rest?  For COVID-19 we do not know but estimates are that it will need to be in the range of 50 -75%.  Obviously the higher the portion of the population which has immunity,  the more effective is the protection.

Finally, what about all this controversy about wearing a mask?  Multiple suggestions, changing recommendations and mixed messages from national leaders have led to considerable confusion. First of all, with the exception of the medical grade N-95 masks (which need to be reserved for medical personnel caring directly for COVID patients), the reason to wear a mask is to protect those around the wearer, not the wearer himself/herself.  All masks, except the N-95, do not block the movement of the virus.  What they do is to block virus-laden droplets and mucus particles which are released by unsuspecting infected persons who may not even know they are infected.  Medical experts have hesitated to urge wide spread use of masks for fear of giving wearers a false sense of security.  Even for those who wear masks the most important guidance is to maintain physical separation, wash hands frequently and avoid touching your face….hard as that is.

As I said in the beginning, we are at war.  Wars bring pain and demand real sacrifice.  But,  WARS CAN BE WON!  We will win this one but we cannot ease up on our resistance too soon or this enemy will come roaring back.  Hang in there!