JohnPatrick.com
Thanks for stopping by. My name is John Patrick and Attitude LLC is the name of my company. My activities include writing, speaking, investing, and board service. My areas of focus include healthcare, Internet and mobile voting, and technology. As you will see in the books I have written, I believe most big problems and big solutions involve Attitude. My latest book is Robot Attitude: How Robots and Artificial Intelligence Will Make Our Lives Better (2019). Robot Attitude and all the prior books are part of a Series called “It’s All About Attitude“. You can find all the details about each book here.
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When I published Election Attitude – How Internet Voting Leads to a Stronger Democracy in 2016, I thought Internet mobile voting could be in place by 2018 in a number of counties around the country and then ready for widespread use by 2020. How wrong I was! The momentum against the idea gained strength as media coverage of Russian meddling caused fear among secretaries of state and election officials. The nail in the coffin, for now, was the incredibly incompetent use of technology by the Democrat party in Iowa. This article is not another plea from John about the virtues of mobile voting. Instead, the focus here is about the huge push for Vote by Mail.
I would like to make two macro points before I get into some specifics. First, the founding fathers made it very clear in the Constitution, Section 1, Article 4 the States have the ball when it comes to managing their election processes. In theory, the Federal government could overrule and take over voting, but I believe turning voting into a National process is politically impossible. The result is the country will have to live with a hodgepodge of voter registration and voting procedures. With a paper based system, this is going to cause problems in November as I will describe shortly.
The second point is the matter of “comparison”. Political and computer science pundits compare Internet voting to a perfect system of perfect computers, perfect networks, no hacking, no malware, etc. The perfect system will never ever exist. I would like to see us compare Internet voting to the paper based system which is expanding. That is the subject of this article.
Problems at the Polling Places
In some cases, availability of convenient polling places is a problem. Election officials in Arizona in 2016 reduced the number of polling sites as part of a purported budgetary necessity. The 70% reduction in polling places from 200 in 2012 to 60 in 2016 resulted in one polling place per 21,000 voters. Hundreds of thousands of voters appearing for the March 22 primaries were confused, inconvenienced, and outraged at the excessive wait times. Many Arizonans left the polls in disgust. Others waited as much as five hours. Arizona was not alone in reducing the number of polling places. Rhode Island opened only 144 of the state’s 419 polling places for the April 2016 primary. Open government advocate John Marion of Common Cause Rhode Island said, “Voters could be confused because their polling place may have changed from what it was the last time they voted.”
In Brooklyn, New York, there was a range of complaints during the April, 2016 primary. Faulty ballot scanners caused continuing interruptions and delays. Inadequate staffing at polling sites and poll workers failing to open up sites on time prevented some people from voting because the voters could not wait. Many voters reported their names were mysteriously missing from the voter rolls, so they were not allowed to vote. The New York City Board of Elections confirmed more than 125,000 Democratic voters in Brooklyn were removed from the rolls. Voters complained there were numerous errors caused by the purging of entire buildings and blocks of voters. The Brooklyn Board of Elections Executive Committee voted to suspend their Chief Clerk without pay pending an internal investigation.
Crazy things happen at polling places. Fights have broken out in the lines. Inexperienced poll workers have given bad advice and turned people away. Although trying to help confused voters, the poll workers could not avoid seeing how some people voted causing angst on both sides.
One might say the solution to the polling place problems is to move to Vote by Mail. Pushed along by the pandemic, the idea has gone from tempting to mandatory in the minds of many. However, let us consider some realities of paper ballots we don’t hear much about.
Problems with Ballots
During the March 15, 2016 primaries in Florida, the hanging chad problem was resolved, but other problems with ballots persist and new ones arose. According to the Supervisor of Elections Office, the voters in one precinct in Flagler County were given the wrong ballots, resulting in about 30 people who voted for the wrong county commissioner candidates. The county election was not impacted and there was no effect on the Presidential race, but errors in handling paper ballots are significant.
In Orange County, Florida, during the 2016 primary, about a dozen of the 251 precincts ran out of ballots. As early as 9 a.m., the Pinecastle Masonic Lodge and several additional precincts ran out of both Democrat and Republican ballots. At some precincts, the order to print more ballots was incorrect. Instead of printing more Presidential ballots, more city ballots were printed. Voters were told to come back later. More than a dozen citizens protested outside the Orange County Supervisor of Elections Office. The Supervisor had absentee ballots printed and hand-delivered to voters’ homes or at workplaces later in the day. Also, several polling places in Orange County had problems verifying voter registration. The tablet computers used to swipe a voter’s driver license had technical problems. These locations had to request delivery of printed registration books from the archives.
In Polk County, Florida, a precinct poll worker couldn’t find the Democratic primary ballots. When the worker opened the polling place, the volunteer only handed out the Republican ballots and told Democrats they couldn’t get a ballot. Voters called the Supervisor of Elections Office, which told the poll worker where to find the ballots. In another case, ballots were loaded on a truck for delivery. The driver got lost. These are a few examples of ballot problems which happened in many states during the 2016 Presidential primary.
Ballot Complexity
Polling place or mail in, the current voting methods can be subject to error because they depend on a certain level of a person’s knowledge of the voting process. Some ballots are not well designed and can be confusing. Some ballots require a simple choice: vote for A or vote for B. The design of some other ballots is not so straightforward.
In Voting Technology: The Not-So-Simple Act of Casting a Ballot (2009), Paul Herrnson, Richard Niemi, and Michael Hanmer reported on their research into the complexities of voting. The authors described election ballots as having curiosities and inconsistencies in their format.
Ballot instructions, candidate and party listings, party symbols, and, in general, variations that result from a complex and highly decentralized election system provide ample opportunity for all but the most sophisticated voters to misunderstand, mismark, or spoil their ballots and for all voters to feel confused and frustrated. The authors cited the enormous disparity in ballot designs across the states and to individual state designs inconsistent and needlessly complex.
The most famous example of ballot complexity is the butterfly ballot problem in Florida in 2000 when 19,235 people voted for both Bush and Gore. None of those votes counted. It was 4% of Palm Beach County votes. There are many other examples. Most recently, in the North Carolina primary, the selection of a senatorial candidate was placed below the ballot instructions at the bottom of page. Thousands of voters did not notice and did not make a choice. More lost votes.
Early Voting
Many states provide a method for eligible voters to cast a ballot prior to Election Day. These early votes may occur during a defined early voting period or by requesting an absentee ballot. Colorado, Oregon, and Washington have been using Vote by Mail for a long time and have enjoyed increased voter turnout as a result. However, there are problems. On Super Tuesday, four million people in California voted early. I don’t know the exact number but it is safe to say a significant number may have voted for Klobuchar, Steyer, or Mayor Pete. All three dropped out of the race before Super Tuesday. More votes thrown away.
The other problem is, because of Covid-19 fears, many more states are being pushed to Vote by Mail. They will be deluged with envelopes. Budget cuts will likely reduce staff. Votes will not be counted timely. Forget about staying up late on November 3 to see who won. It will take days for the counting. Mistakes will be made. Recounts may be justified and stretch out timelines even further. It is logical to expect when 100 million ballots get dumped into the system there will be human errors.
A survey discovered voting on Election Day has been the most popular form of voting with 60.6% of voters casting a regular ballot in person. Others voted by domestic absentee ballot (17.5%); by early voting before Election Day (10.7%); and by mail voting (7.6%). These numbers will surely change for November.
The problems with overseas voting for six million people remain. Soldiers and ex-pats have been conditioned to ballots not getting to the polling place on time and, if they do, they may not get counted unless there is a tie. So why bother voting? West Virginia conducted pilot mobile voting for overseas military. It was quite successful but was subsequently criticized, unfairly in my opinion, as being insecure. There were no problems with the voting and voter satisfaction and participation were excellent.
Mail Votes Lost or Not Counted
Some people lose their ballot or mail it too late for it to be counted. The pipeline from deciding to vote to having a vote actually counted can be long and frustrating. Charles Stewart III, the Kenan Sahin Distinguished Professor of Political Science at MIT, studied the question of whether voting by mail causes more lost votes, compared to in-person voting. In a published study, “Losing Votes by Mail”, Stewart concluded, “The number of lost votes through the Vote By Mail system in 2008 may have been as large as 7.6 million.” The number represents approximately one in five citizens who attempted to vote by mail. These votes include voters at home and abroad. The 7.6 million lost votes included 3.9 million absentee ballots requested but never received, 2.9 million ballots received but not returned, and .8 million returned but not counted.
The ballots received but not returned can be due to a ballot lost in the mail or the voter deciding to vote at the polls or not vote at all. Votes returned but not counted can be a result of numerous kinds of errors. Typical errors include the ballot envelope not being signed, the name not matching the voter registration list, failure to provide the voter’s address, missing or bad signatures, no witness signature (if required), no ballot application on record, missed deadline, already voted in person, or the voter had died. The President recently said a state had sent every voter a ballot in the mail. That was not true. The state had sent an application for an absentee ballot. The time allotted to sending the application, the voter sending it back, the state sending them a ballot, and then the ballot being returned all on the backs of USPS. It is likely all will not make the due date to be counted.
Voter Fraud
The purported frequency and extent of voter fraud is a highly controversial issue. There can be no question there is a perception of voter fraud. Vivid stories have been passed through generations. One of the most famous is a reported quote from Earl Long (1895-1960), Governor of Louisiana. “When I die, if I die, I want to be buried in Louisiana, so I can stay active in politics.” Losing candidates often contribute to the lore. The facts however, do not demonstrate voter fraud. In 2012, Loyola law professor Justin Levitt estimated, “Over the previous twelve years, the voting fraud rate was 0.000002%.” He found only nine instances of specific allegations of voter fraud out of approximately 400 million voters. Voter fraud was used as the reason for Governor Scott Walker’s determination to make the special voter ID requirements in Wisconsin more stringent and difficult. Even though a 2014 study at Marquette University found 39 percent of voters from a Wisconsin state-wide poll believed voter fraud affected a few thousand votes at each election, no claims of voter fraud were substantiated.
Some politicians have alleged voter fraud is rampant and is jeopardizing the integrity of American elections and democracy. The allegations claim elections are being stolen by unscrupulous registration activists, vote buyers, and illegal immigrants voting. Despite a history of stories about fraud, in my research for Election Attitude, I found no contemporary charges voter fraud is rampant. In The Myth of Voter Fraud, Lorraine C. Minnite describes the results of her research to find evidence of voter fraud. She contended that while voting irregularities created by our complex and fragmented electoral process in the United States are common, intentional voter fraud is quite rare. Minnite examined public records obtained from all fifty state governments and the U.S. Department of Justice. She concluded, “Voter fraud is in reality a politically constructed myth intended to further complicate the voting process and reduce voter turnout.”
Although legally fraud, a problem with Vote by Mail is coercion. Helpful agents may visit a nursing home and offer to “help” people vote. A spouse may handle two votes for the family. There could be a lot of “helpful” persons involved but unseen in the election process. Special ballot mailboxes placed next to USPS mailboxes in certain neighborhoods could be transplanted from a pickup truck to a trash dumpster.
Weather
Regardless of the expansion of Vote by Mail, millions of people will go to the polls despite the weather and possible need for masks. Even with an adequate number of polling places and a sufficient quantity of the correct kind of ballots on hand, other problems can affect voter participation. Long lines in bad weather can dissuade voters, especially the elderly or people with special needs, from voting. Some polling places make voters wait outside since they can only accommodate a small number of voters inside. This will be exacerbated by social distancing. A friend told me her sister in Wisconsin waited outside in 40 degree weather and high winds for an hour and 45 minutes to vote in 2016. Her son in Florida had to wait outside five hours in the sun. Work schedules can make it impossible for some workers to get adequate time to drive in bad weather to and from the voting location. Inadequate, convenient parking can prevent some people from voting particularly in hazardous weather. In some polling places, there is insufficient, designated handicapped parking.
People with Special Needs
Some voters may be ill and homebound on Election Day. Other voters may not try to vote because disabilities may impose physical limitations in using the voting equipment. There are at least 35 million voting-age people with disabilities in the United States, representing 1 out of 7 voting-age people. This number is likely to grow with the aging of the population. People with disabilities have lower voter turnout than people without disabilities. Lisa Schur, Associate Professor at Rutgers University, said, “Twelve surveys covering the 1992-2004 elections, using varying samples and definitions of disability, found eligible citizens with disabilities were between 4 and 21 percent less likely to vote than eligible citizens without disabilities.” The lower voter turnout among people with disabilities appears to be caused in part by their greater likelihood of experiencing voting difficulties, including with Vote by Mail.
Conclusion
The problems with existing voting systems are challenging. The Federal Government provided funding for new voting machines in 2002, but did not provide funding to maintain or replace them when they became out dated. Unfortunately, the machines are at the end of their life cycle, in fact at a crisis, and have not been replaced. One alternative to resolve the problem is to patch the existing system of antiquated machines. Another alternative is to embrace an election attitude.
An election attitude offers a practical approach to voting. A key component of the new attitude is Internet voting. It uses mobile devices and the Internet to enable citizens to vote from the comfort and privacy of their home or at a local library. Though the risks of Internet voting are real and cannot be ignored, there are numerous benefits to adopting Internet voting. With Internet voting it can replicate successful web services such as Amazon which is used by millions of people daily. If voting online could reach the level of adoption of e-commerce, it would be possible for voter participation to increase significantly. With a changed focus, increased funding, changes in election registration and security, and increased access for people with special needs, I believe the voter participation rate would be greatly improved. I urge all of us to compare our fears of the Internet with the challenges of the paper based system we have today.
The weather rained on their parade this past week, but today will be a really big one for astronauts Doug Hurley and Bob Behnken. They arrived in Florida last week to prepare for their launch into space in Crew Dragon atop a SpaceX Falcon 9 rocket. The launch will make space history as the first private launch vehicle to put humans into orbit. The mission will be the first NASA spaceflight to depart from American soil since NASA retired its space shuttle fleet in July 2011. I can’t wait to watch the proceedings this afternoon.
On Thursday, I was privileged to participate in a fireside chat with Bob Reby, “How to Strengthen Our Democracy in Troubling Times”. A few dozen people attended the Zoom webinar. Bob and I discussed the following :
- Voting with Paper or Internet: Which is more secure, accurate, private and verifiable?
- How the U.S. can use blockchain technology to safeguard ballots from hackers and foreign adversaries
- Cautionary Case Studies: What went wrong and how mistakes could have been avoided
- Success Stories: Internet voting in foreign countries and pilot programs in U.S. states
As of Friday’s close, Tesla market capitalization continued to climb and finished at $155 billion. Zoom reached a market cap of $50 billion. The five giant tech company market caps maintained their meteoric level. All five companies are global, but to put their massive valuation into perspective, it now represents 23% of the market cap of the U.S. S&P 500. Shareholders are happy but government regulators and politicians are gearing up for new regulations and anti-trust hearings. I believe pressure on big tech will continue to mount.
| MAGFA Market Cap (05/29/20 4:30 PM) | ||
| Microsoft | $1.390 | Trillion |
| Apple | $1.378 | Trillion |
| $0.963 | Trillion | |
| $0.641 | Trillion | |
| Amazon | $1.218 | Trillion |
| Total | $5.590 | Trillion |
| S&P 500 4/30/20 | $24.140 | Trillion |
| MAGFA | 23% | |
Humans have been very fortunate to have been protected by vaccines for more than two centuries. The path to get from the identification of an infectious disease to have an effective vaccine is complex, to put it mildly. The issues include research and development, testing, procurement of dependable funding, scaleable manufacturing, equitable distribution, assured safety, management of public fears of inoculation, and global political considerations. Covering all these issues is beyond the scope of this article, but I hope to shed some light on some important aspects of vaccinations and present a view of what we might see in the future. First, a glimpse into the history.
Edward Jenner was a country doctor in Gloucestershire, England. He was a generalist, not a specialist. Jenner had a strong interest in natural history and he was very good at observing basic behaviors. Health Affairs, in “The History Of Vaccines And Immunization: Familiar Patterns, New Challenges”, delved into Jenner’s experience in considerable detail. It reported that sometime during the 1770s, Jenner heard a Bristol milkmaid boast, “I shall never have smallpox for I have had cowpox. I shall never have an ugly pockmarked face.” Years later, Jenner developed a cowpox inoculation hypothesis for smallpox.
Health Affairs described the remarkable scenario about how Jenner performed the world’s first vaccination in 1796. “Taking pus from a cowpox lesion on a milkmaid’s hand, Jenner inoculated an eight-year-old boy, James Phipps. Six weeks later Jenner variolated [inoculated] two sites on Phipps’s arm with smallpox, yet the boy was unaffected by this as well as subsequent exposures.”
Jenner conducted a dozen similar experiments and documented sixteen additional case histories. With no government or publishing subsidies, Jenner published his studies in “Inquiry into the Causes and Effects of the Variolae Vaccine”. Health Attitude said the work, “swiftly became a classic text in the annals of medicine: His assertion “that the cow-pox protects the human constitution from the infection of smallpox” laid the foundation for modern vaccinology”.
As Dr. Anthony Fauci and others predicted, the mortality has gotten worse since we reached the top of the curves. If we all do a good job in hygiene, screening, distancing, and masks, the country will be able to re-open without uncontrollable spikes in cases. The government is pulling out all stops for therapeutic solutions, as Dr. Kuhn of the FDA has described. Testing is ramping up rapidly. The remaining tool needed is a vaccine for Covid-19 and, hopefully, other variations which may follow.
Significant progress is being made by Moderna Therapeutics, CureVac, Inovio Pharmaceuticals, and others. All are going as fast as possible to advance the clinical trials. Nevertheless, the approach they are taking uses biological DNA and RNA as the core ingredients. As advanced as the current development process is, vaccines as we know them have a number of shortcomings. The most visible is they take a long time to develop and manufacture. Potentially more significant is they can become obsolete if and when the virus evolves, which it will. There are already multiple strains, and there will be more. Finally, the immune response the vaccines produce may not be strong enough to be effective.
A totally new approach is under development using synbio. The Bill and Melinda Gates Foundation has put $60 million into coronavirus research including for the synbio effort. Synbio stands for synthetic biology. Synbio is mostly about the design and construction of new biological parts, devices, and systems, and the re-design of existing, natural biological systems. More specific to the issue of the day, synbio may replace the DNA and RNA ingredients mother nature has provided for the development of vaccines with synthetic ingredients. Huge advances in cloud computing, AI, genetic sequencing, and collaborative tools are making timelines possible which were unthinkable in the recent past.
A vaccine made from synthetic ingredients can potentially offer some significant advantages. The big one is scalability. Synbio vaccines could be produced efficiently for millions or even billions of doses. Another advantage is synthetic ingredients do not need to be refrigerated. This would be a huge benefit for places like sub-Saharan Africa.
Synbio vaccines are developed using computer models, not flasks and test tubes. With billions of calculations, a nanoparticle can be designed which has the exact properties desired. The really big breakthrough with synbio is the attachment of viral molecules to the nanoparticle. Neil King at the University of Washington and his synbio colleagues knew there would be another coronavirus epidemic, like the SARS and MERS outbreaks before the current Covid-19 outbreak. King said, “…there will be another one after this,” perhaps from yet another member of this virus family. We need a universal coronavirus vaccine.” One vaccine for all corona viruses. That will be the breakthrough.
Sharon Begley wrote a beautiful article in STAT which explains the synbio efforts underway in much more detail. See To develop a coronavirus vaccine, synthetic biologists try to outdo nature. STAT has great articles about life sciences and the fast-moving business of making medicines.
Dr. Craig Venter, an American biochemist, geneticist, and entrepreneur known for being one of the first to sequence the human genome, is an advocate for a new and innovative digital approach for the development of vaccines. Venter said the current process used for developing the H1N1, otherwise known as swine flu, vaccine took many months and the supply was barely adequate to cover healthcare workers. He said if the H1N1 virus had been as deadly and widespread as some had forecasted, we would have had a very bad situation.
Venter envisions vaccines being developed using synthetic DNA instead of “billions of eggs”. He has written how DNA data about a virus to be protected against can be developed into a digital recipe and emailed to laboratories which could then begin production of the vaccine at facilities all over the world within 12 hours. Venter said a couple of years ago FDA approval was imminent. The Covid-19 crisis has caused an increase in the sense of urgency.
One final thought about the future of vaccinations has to do with syringes, essential for delivering vaccine. I will be the first to admit, I don’t like needles. My wife and daughter, both nurses, think I am a wuss. I am not afraid, I just don’t like the experience. Unfortunately, many people are afraid for themselves or their children and transfer the fear into inaction. The fear jeopardizes their own health and also the public health.
Syringes could become a thing of the past. Scientists at the Hilleman Labs in India have developed micro-patches which can be used for routine immunizations. The patches are cheap to produce and easy to store without chilling. The patches don’t need special training to be applied, and potentially will be able to be used by consumers at home. Delivered by drones, the patches could become a potential lifeline for rural and poor families around the world. Vaccination by patches could become a reality before the end of the decade.
Saturday was sunny and warm in Connecticut. I went out for a walk and saw a lot of people. Almost none were wearing masks. What were they thinking? At a homeowners association meeting in FL before I came North, a woman said she did not need to wear a mask because she is not infected. There are multiple ways such a comment could be interpreted but, to me, the salient point is, how does she know she is not infected? Incubation and the emergence of symptoms is typically five days after getting the virus. During those five days, a person can infect others. Masks are not to protect you, they are to protect others. If we all wear them, we are all more safe. Such a simple principle.
A really big week is coming up for Doug Hurley and Bob Behnken. They arrived in Florida this week to prepare for their launch into space in Crew Dragon atop a SpaceX Falcon 9 rocket. The launch will make space history as the first private launch vehicle to put humans into orbit. The mission will be the first NASA spaceflight to depart from American soil since NASA retired its space shuttle fleet in July 2011. I can’t wait to watch the proceedings. NASA officials announced on Friday there were no showstoppers found during a crucial flight readiness review (FRR) for SpaceX’s Demo-2 mission.
Reminder: The fireside chat with Bob Reby, “How to Strengthen Our Democracy in Troubling Times”, will be happening in one week. You can register here.
The Zoom conference will be on May 28, 2020 6:00 PM Eastern. Join from a PC, Mac, iPad, iPhone or Android device.
Bob and I will discuss the following :
- Voting with Paper or Internet: Which is more secure, accurate, private and verifiable?
- How the U.S. can use blockchain technology to safeguard ballots from hackers and foreign adversaries
- Cautionary Case Studies: What went wrong and how mistakes could have been avoided
- Success Stories: Internet voting in foreign countries and pilot programs in U.S. states
We look forward to seeing you there!
The How We Feel app continues to gain momentum. States are hiring people to be contact tracers. However, if we all donate our non-personally-identifiable data to help scientists track the virus, it may prove a digital approach can work, or at least help. The app is completely private. No login required. If you don’t have the app yet, get it here for Apple or here for Android.
As of mid-afternoon Friday, Tesla market capitalization is up to $152 billion. The five giant tech company market caps continued to climb. All five companies are global, but to put their massive valuation into perspective, it now represents 23% of the market cap of the U.S. S&P 500. Shareholders are happy but government regulators and politicians are gearing up for new regulations and anti-trust hearings. I believe pressure on big tech will continue to mount.
| MAGFA Market Cap (05/21/20 3:30 PM) | ||
| Microsoft | $1.387 | Trillion |
| Apple | $1.377 | Trillion |
| $0.963 | Trillion | |
| $0.668 | Trillion | |
| Amazon | $1.214 | Trillion |
| Total | $5.608 | Trillion |
| S&P 500 4/30/20 | $24.140 | Trillion |
| MAGFA | 23% | |
In the old days of medicine, a common mantra was “Do as the doctor told you”. In Health Attitude: Unraveling and Solving the Complexities of Healthcare, I suggested patients should take more responsibility for their health and question their doctors and collaborate with them. I am quite fortunate to know a lot of doctors, some who are part of my care team, and others who are just friends. I learn from all of them. Two doctors who I pay very close attention to and listen to all the words they say are Dr. Robin Cook and Dr. Atul Gawande.
Robin Cook, 80, is an American physician and novelist who writes about medicine and topics affecting public health. More specifically, he writes medical thrillers, and has published nearly 40 of them. Probably the most famous is Coma (1977), which has been adapted for both film and television. A few other of his well known novels include Sphinx (1979), Brain (1980), Mindbend (1985), Outbreak (1987), Mutation (1989), Vital Signs (1991), Toxin (1998), Nano (2013), and Cell (2014). His books have sold nearly 400 million copies worldwide. I read mostly non-fiction, but whenever I need a break from learning, I read another Robin Cook medical thriller. Although Cook’s writings are novels, they probe deeply into important healthcare issues. They are really great books. Hard to put one down.
The other doctor to listen to is Atul Gawande, 54, a Brooklyn born surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital in Boston. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and also a Professor of Surgery at Harvard Medical School. In public health, he is executive director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit that works on reducing deaths in surgery globally. He is also the Chairman of healthcare venture Haven, which is owned by Amazon, Berkshire Hathaway, and JP Morgan Chase.
As a Rhodes Scholar with degrees from Stanford University, Balliol College at the University of Oxford in England, and Harvard Medical School, Dr. Gawande is a superb author and speaker. All four of his books are excellent reads. His third book, The Checklist Manifesto: How to Get Things Right (2009) was a best seller. No one likes to talk about the error rate in surgery, but suffice it to say the numbers are not pretty. Thousands of people are harmed in some way.
The ChecklistManifesto is an easy read because the recommendations are practical and understandable. His extensive examples from medicine and aviation make the point about how easy it is for people to forget things which can jeopardize the lives of others. Being a pilot, I already appreciated the importance of checklists, but had not thought of them in medicine. When learning to fly, the checklist is fundamental. You learn to use it all the time, whether you have ten hours of flight experience or 10,000. The book is replete with examples of how things went wrong in a medical setting when a simple step was skipped due to the frenetic pace of the operating room and possible distractions and interruptions. Dr. Gawande’s focus and enthusiasm for patient safety has had a positive impact around the world.
Being Mortal: Medicine and What Matters in the End (2014) was another bestseller and was the basis of a documentary for a PBS television series . It discusses end of life choices about assisted living and the effect of medical procedures on terminally ill people. It challenges many traditionally held notions about the role of medicine. This is an outstanding and highly relevant book. I first met Dr. Gawande in New York in 2010 at a breakfast hosted by IBM. It was followed by an articulate and emotional speech called “How To Live When You Have To Die” based on Being Mortal.
On the coronavirus/Covid-19 front, the information explosion continues. Axios described it as an infodemic of misinformation and disinformation. As biologists, epidemiologists, immunologists, virologists, and researchers around the world intensely study all aspects of what we are facing and why, what emerges to me is recognition of how much is not known. In a number of areas, there are disagreements. Some say the differences are political, but I attribute them to the different backgrounds and areas of experience. Fortunately, there are a number of excellent articles which explain the risks and how to minimize them. One of best is by none other than Dr. Atul Gawande.
In “Amid the Coronavirus Crisis, a Regimen for Reëntry“, Gawande breaks down the risks and actions into four areas which he calls a combination therapy, like a drug cocktail. The elements are all familiar: hygiene measures, screening, distancing, and masks. Gawande says, “Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus.” Following are a few highlights about the four elements.
Hygiene
Studies have confirmed a dedication to hand washing can cut infections nearly in half. The key, Gawande says, is “washing or sanitizing your hands every time you go into and out of a group environment, and every couple of hours while you’re in it, plus disinfecting high-touch surfaces at least daily.” The more you wash your hands the more effective it becomes.
Distancing
Hygiene is essential but not sufficient because most of the infections occur by transmission from others. This is where distancing comes in. Transmission can occur from coughing, sneezing, shouting, singing, and even breathing. Your risk depends on how close you are to an emitter and for how long. Dr. Erin Bromage wrote in “The Risks – Know Them – Avoid Them” about the community choir in Washington State.
“The choir avoided the usual handshakes and hugs hello, people also brought their own music to avoid sharing, and socially distanced themselves during practice. A single choir member with no symptoms infected most of the people in attendance. “The choir sang for 2 1/2 hours, inside an enclosed rehearsal hall which was roughly the size of a volleyball court.” Singing, more so than talking, aerosolizes respiratory droplets exceptionally well. The 2 1/2 hour exposure “ensured people were exposed to enough virus over a long enough period of time for infection to take place.” “Over a period of 4 days, 45 of the 60 choir members developed symptoms, 2 died.”
Distancing may be much more important than we all realize. The beauty of it is how simple it is to implement. What is unique about coronavirus is it can spread before the carrier has any symptoms. The average incubation period is five days. Gawande said, “A single unchecked case can lead, over two months, to more than twenty thousand infections and a hundred deaths.”
One more thing. Six feet is not always enough if people are unmasked. Dr. Bromage said, “A single sneeze releases about 30,000 droplets, with droplets traveling at up to 200 miles per hour. Most droplets are small and travel great distances (easily across a room).”
Screening
Hygiene and distancing are not sufficient. Screening plays a key role and will be essential as the country begins to open up. At Mass General Brigham in Boston where Dr. Gawande works, employees are given an app needed to enter a building. The app asks about symptoms such as, “a new fever, cough, sore throat, shortness of breath, loss of taste or smell, or even just nasal congestion or a runny nose.” Based on responses, the employee gets a red or green light from their app. Some workplaces will no doubt be using the contactless thermometers to look for fever. The other part of screening is testing. While there is no debate about the bumpy start, the number of tests has now risen above ten million and is ramping up rapidly. Availability and use of testing will go much higher as reopening accelerates.
Masks
Hygiene, distancing, and screening/testing are essential but not sufficient. That is why we need masks. Whether it is a handkerchief, teeshirt, one layer, two layer, or industrial N95 mask, the use of masks is universally a very good thing. Research by an international consortium of scientists found “if at least sixty per cent of the population wore masks that were just sixty-per-cent effective in blocking viral transmission—which a well-fitting, two-layer cotton mask is—the epidemic could be stopped.”
The benefit of covering of your face when you go outside is a bit subtle. A bandana, non-medical mask, or homemade cloth mask does not protect you from viruses in the air. However, it does prevent you from breathing, coughing, or sneezing on someone else. So, if everybody wears a mask when they are near others then everybody gets protected. It is a very good idea and, like distancing, is easy to implement. While out for a two-mile walk yesterday, I saw a lot of people out walking. I would say half wore masks. What are they thinking? Where needed, I zig zagged my way across the street to keep my distance even though I wore a mask. The Surgeon General did a great job explaining the need for masks. Listen to him on YouTube (fast forward to 1:10 to bypass what the President had to say).
Summary
None of the four elements solves the problem. However, taking each of the four seriously will have a huge impact. Dr. Gawande says there is a fifth element to make it happen: culture. You can say it is not being selfish. It is being a team player. It is believing if you take care of others, they will take care of you. Many ways to say it, but I know you get the point. I am optimistic about the reopening because I believe the governors are doing it thoughtfully. There will be some abusers who don’t think of others. Some hotspots will pop up, but they will get isolated and create an example for others to avoid. One last thing. Today, I checked in with the How We Feel app for the 26th time. I hope you are doing it also. The app can supplement contact tracing. All will benefit from each of us donating our (non personally identifiable) data to the researchers who are dedicated to learn and prepare.
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There was a lot of interest in my post about heart cell implants. Bill McGowan, founder and CEO of MCI was the oldest recipient of a heart transplant when he got his in the late 1980’s. The surgery was done in Pittsburgh at UPMC. Mr. McGowan and his wife donated $1 million the following year to build the William McGowan Center for Regenerative Medicine. Interesting article about this is here.
The amount of information about Covid-19 is overwhelming. One thing clear to me is experts do not all agree on various aspects of the virus and the disease it causes. This is because there is much not yet well understood. For example, is the coronavirus airborne or droplets? Or both? A friend forwarded me an article by Dr. Erin Bromage titled, “The Risks – Know Them – Avoid Them“. Dr. Bromage is a Comparative Immunologist and Professor of Biology (specializing in Immunology) at the University of Massachusetts Dartmouth. His article is easy to read and offers practical explanations of the risks specific to different environments such as restaurants, workplaces, churches, birthday parties, and indoor sports. He also explains in practical terms the differences between droplets and aerosols and the effects of various encounters with fellow citizens. A very good read. Another not to miss article is “Amid the Coronavirus Crisis, a Regimen for Reëntry” in the New Yorker by Dr. Atul Gawande. He distills all the issues into four basic steps to take to stay safe.
The How We Feel app continues to gain momentum. States are hiring people to be contact tracers. However, if we all donate our non-personally-identifiable data to help scientists track the virus, it may prove a digital approach can work, or at least help. The app is completely private. No login required. If you don’t have the app yet, get it here for Apple or here for Android.
As of mid-afternoon Friday, Tesla market capitalization is up $20+ billion to $148 billion. The five giant tech company market caps climbed another couple of hundred billion for the week. Quite a bit higher than at the end of February. All five companies are global, but to put their massive valuation into perspective, it now represents 23% of the market cap of the U.S. S&P 500. Shareholders are happy but government regulators and politicians are gearing up for new regulations. I believe pressure on big tech will continue to mount.
| MAGFA Market Cap (05/15/20 4:15 PM) | ||
| Microsoft | $1.389 | Trillion |
| Apple | $1.334 | Trillion |
| $0.938 | Trillion | |
| $0.601 | Trillion | |
| Amazon | $1.202 | Trillion |
| Total | $5.463 | Trillion |
| S&P 500 4/30/20 | $24.140 | Trillion |
| MAGFA | 23% | |
Fifty-three years ago, the first human heart transplant took place at Groote Schuur Hospital in Cape Town, South Africa. The daring surgery was performed by Dr. Christiaan Barnard. The world’s media covered the progress of the patient, Mr. Louis Washansky, on an hourly basis. Mr. Washansky lived with his new heart for 18 days. Barnard’s second transplant patient led an active life for more than 18 months. His fifth and sixth patients lived for almost 13 and 24 years, respectively.
Today, approximately 3,500 heart transplants are performed every year. Recent figures show 75% of heart transplant patients live at least five years after surgery. Nearly 85% return to work or other activities they previously enjoyed. Many patients enjoy swimming, cycling, running, or other sports.
The last paragraph is the good news. The bad news is more than 115,000 people in the United States are on the waiting list for a lifesaving organ transplant (not just hearts). Sadly, 8,000 people per year die while waiting. Fortunately, there is an emerging alternative called regenerative medicine. I have written ten stories about regenerative medicine here in my blog. Today’s story is about a new breakthrough: lab-grown heart cells have been implanted in a human for the first time.
New Atlas has published more than 50,000 articles covering advances in various fields of technology. In January the site published “Lab-grown heart cells implanted into human patient for the first time“. The article describes a research plan for patients with ischemic cardiomyopathy (IC). IC is most commonly caused by coronary heart disease, the leading cause of death in the United States. IC leads to the heart’s decreased ability to pump blood properly.
Professor Yoshiki Sawa, a cardiac surgeon at Osaka University in Japan, believes regenerative medicine will be a cure for IC. The potential cure starts with induced pluripotent stem cells (IPSCs), a Nobel Prize-winning technology developed at Kyoto University in 2006. The IPSCs are created by harvesting cells from the patient’s own tissue and then inducing the stem cells to transform themselves into heart cells called cardiomyocytes.
The heart has a few billion cardiomyocytes and, in a patient with IC, some of those cells are weakened. Dr. Sawa developed a technique to turn IPSCs into sheets of 100 million heart muscle cells, which can be grafted onto the heart to promote regeneration of damaged muscles. The sheets are biodegradable and, once implanted on the surface of the heart, release growth factors which encourage the new cells to grow and boost cardiac function. The sheets on which the cells were deposited will dissolve.
The technique was first tested on pigs and shown to improve heart function. Based on that result and supporting research, Japan’s health ministry approved a research plan involving human subjects. The first patient received the graft in January and is recovering in the hospital. Over the next three years, the clinical trial will add nine more patients. If the trial proves successful, many lives will be saved.
If you are interested in regenerative medicine, you may want to take a look at “3D Printing of Body Parts“.
While driving back to CT from PA, it became time for lunch. What to do? McDonalds made it really easy. We pulled into one of four parking spaces designated for delivery. We placed a lunch order on the iPhone McDonalds app. My credit card is stored in the app so there was no need for anyone to touch any money or credit cards. Five minutes later, a young man named Aaron came out with his mask and handed us the lunch. Not quite the same as sitting down inside the restaurant, but very efficient and safe. Way to go, McDonalds.
