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.
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.
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).”
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.
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).
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.