Where are we?  Where are we headed?

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!

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.

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.

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.

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.”

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.

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!

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.

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.”

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.”

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!” 

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.

 

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.

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.

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.

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.

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.