Medical Priorities vs Medical Impossibilities

We live in a society of instant gratification, more than ever. A click of a remote control or a mouse and we can change what amuses us. Food can be delivered to our door, groceries or gourmet meals. When we’re sick, we head to a doctor or dentist for what we hope will be a quick pill, injection or, if necessary, a minor surgery. Our cars are connected and air conditioned. If we are poor, we suffer at every level… but those at the top, those with the money to level the playing field prefer to tilt it more… don’t seem to care. And yes, even with insurance, the cost of healthcare for a serious issue can still bankrupt almost anyone except the wealthy.

We borrow for the now. From credit cards and mortgages, from government bonds to massive federal deficits, from leveraged buyouts, from car loans to student debt. We owe. We stress out. We borrow more. It’s just the way our modern life is designed. Hard to avoid. But the willingness to accept a quick solution often leads us to personal choices and governmental programs that are either inefficient and wasteful or that just plain do not work. We call it throwing money against the wall and hoping some of it sticks. 

We are going to have to borrow a whole lot more to save what we have and to reignite what we want to return after this pandemic. But will our remedy mirror a program where incarcerated felons were getting unemployment checks because of the haphazard way the stimulus package was designed? Or how about the massive push to build and deploy ventilators to save COVID lives? Not enough technicians to run them and ordering and building the wrong kind? 

“With the COVID-19 pandemic sweeping across its shores earlier this year, the U.S. government in April announced orders for almost $3 billion of ventilators for a national stockpile, meant to save Americans suffering from severe respiratory problems brought on by the disease.

“But of the 140,000 machines added since then by the government to the U.S. Strategic National Stockpile, almost half were basic breathing devices that don’t meet what medical specialists say are the minimum requirements for ventilators needed to treat Acute Respiratory Distress Syndrome, the main cause of death among COVID-19 patients, according to a Reuters review of publicly-available device specifications and interviews with doctors and industry executives.

“Only about 10% are full intensive care unit (ICU) ventilators of a type that doctors and ventilator specialists say they would normally use to intubate patients suffering from Acute Respiratory Distress Syndrome or ARDS, the Reuters review found. The remainder - or about 40% - are transport ventilators normally employed for shorter periods but are considered sophisticated enough to be used long enough for ARDS patients to recover.” Reuters, December 2nd. Oh, and it seems as if the Trump administration had an opportunity to expand the vaccine order from BioNtech-Pfizer (which depended on its being vetted as safe and effective) this past summer, but believing falsely that the pandemic was winding down, they did not. It now seems as if we might not get enough vaccine until June or later.

We’ve rushed to find treatments or vaccines to stop this horrific pandemic. By politicizing the effort and giving it a fancy Star Trek name – Operation Warp Speed – we’ve manage to terrify enough people into believing that the vaccine cannot be safe and that we will all be human guinea pigs in a mass inoculation effort. These skeptics just might prevent our acquiring that herd immunity. Even wearing a mask or being safely distanced is now a political statement when it really should not be. The result: the United States, once believed to be a technological leader, is now the nation with the most infections (still rising) and the most deaths (an equally bad statistic), even as countries like China seem to have tamed the beast. As much as the new administration wants to fix this fast, it is stuck with the legacy of lingering failure from the Trump administration.

We are also likely going to face new infectious diseases. We need to prepare. And we need to know that some diseases might not find that magic bullet vaccine or a ready cure; some might just have to work their way into managed care and containment. Such is our story with HIV/AIDS. It’s been around for decades, and at its inception got a reduced priority because it was seen that what too many Americans viewed as “social misfits”: gay men and intravenous drug users. There are so many ways that virus can be spread, although COVID is vastly more contagious. But we still found a path, although it took decades to get from the ravages of so many deaths from AIDS in the 1980s, to moderate and contain the disease.

“As the numbers of COVID-19 infections climb, it’s easy to forget that there are still more than 1.2 million people in the U.S. living with another virus—human immunodeficiency virus, or HIV. When it first swept across the country in the 1980s, HIV was one of the most sobering public health challenges ever faced. It brought a cruel and isolating stigma toward gay men, who died in startling numbers, and it went on to kill 33 million people across the world.

“Times have changed. Now, most people don’t die from the virus. Thanks to continuing medical advances in medications, HIV can now be seen as a chronic disease. People who have it can enjoy long careers, get married, and raise families… ‘The message that we used to give in the early days of HIV was, ‘Let's try to make your remaining days as comfortable as possible.’ Now, it’s treatable. It's not curable, but it is controllable,’ says Merceditas Villanueva, MD, director of the Yale School of Medicine AIDS Program.

“Many HIV providers and public health experts believe they can eventually come close to eradicating the virus by 2030 with a goal known as ‘95-95-95.’ In this vision, 95% of people who have HIV would be diagnosed, 95% of them would be receiving treatment, and of those, 95% would have the virus suppressed (the term used when the amount of virus is so low that the patient with HIV stays healthy and has a greatly reduced chance of passing it to others)…  

“While annual [HIV] infections in the U.S. have decreased by more than two-thirds since the mid-1980s, recent data still show about 38,000 new infections in the U.S. each year between 2014 and 2018. The highest number of new diagnoses are in people between the ages of 20 and 35 (a population believed to most likely be unaware of their HIV status)…

“A collection of antiretroviral therapies (ART) has moved HIV into the chronic disease realm and given young people who are newly infected a close-to-normal life expectancy. In fact, more than half of people living with the virus now are over 50 years old, says Michael Virata, MD, director of HIV clinical services at YNHH’s [Yale New Haven Hospital’s] Saint Raphael Campus.

“‘Really, the basic goal is to treat people with highly active drugs that combat the virus, so we get them to the point where they have undetectable levels of it,’ he says… Patients may be given some combination or ‘cocktail’ of three drugs, and doctors are moving toward two-drug combinations. ‘We are even moving into a realm of longer-acting agents so that people won’t have to take a pill every day,’ Dr. Virata says.” YaleMedicine.org, November 30th. It took us decades to get here. COVID seems scarier since it breeds and spreads through the air we all breathe. 

Are there lessons that we may have forgotten from this earlier epidemic? Oh, it’s still with us, but… Beyond treatment, patience and experimentation, there is testing and contact tracing that helped minimize the impact of HIV. “HIV testing is critical because—as with COVID-19—many people who have the virus don’t know it. An estimated 14% of people with HIV in the U.S. (or 1 in 7) are not aware they have it. Symptoms aren’t always a tip-off, since about a third of newly infected people don’t develop symptoms (two-thirds report flu-like symptoms within 2 to 4 weeks of infection) but are still able to transmit it to others.

“In 2006, the Centers for Disease Control and Prevention (CDC) recommended offering HIV tests to anyone between the ages of 18 and 65 coming into the health care system for any reason, regardless of their background or risk factors. [Dr. Lydia Aoun-Barakat, medical director of YNHH’s HIV clinic] would go a step further. ‘Every single person should be tested for HIV—annually, if they are at higher risk,’ she says. High-risk groups would include those who use drugs and share needles or engage in unprotected sex… Testing is important because once a person is diagnosed, he or she is more likely to be treated, and therefore less likely to spread the disease to others, says Dr. Virata.” YaleMedicine.org.

Relying on mythology, a strong but factually vapid belief and hoping for a quick and easy fix and return to normal – reactive vs proactive – have never worked for any big, serious problems. We need committed, scientifically solid and dedicated efforts to prepare for what is likely to come. And if you do not believe in “educated elites,” the next time you have a serious medical issue, be sure to call QAnon for the treatment.

I’m Peter Dekom, and I always wonder why people are terrified by truth and facts, when basing decisions on truth and facts is the only way to solve real problems.