A guide for the perplexed
Dr. Peter Simon offers easy-to-understand words of wisdom to help guide us in our efforts to navigate through the fog of the coronavirus pandemic
Dr. Peter Simon
To do so, realistically, would depend upon the ability to have a comprehensive system of testing in place – to detect those who have contracted the virus, to detect those who have antibodies for the virus, and to determine the spread of the virus in the “asymptomatic” population.
It will also require research on how best to treat the disease and its residual aftermath, vaccine development and then manufacture, and scaling up enough production and supply of personal protective equipment for all health care workers.
The distance between that optimistic “wish” and the reality on the ground seems problematic, at best.
Further complicating the equation is the distance between the haves and the have-nots in Rhode Island and in the nation.
That gap was perhaps best illustrated in an op-ed, “What Does the Good Life Look Like Now?” by Trish Hall, published on April 18. Hall details all the luxuries in her life that the coronavirus pandemic has forced her to give up – the once-a-week trainer, the twice-a-week Pilates classes, the monthly facial, the hair colorist, regular theater tickets, daily cappuccinos, as well as dinners that cost $70 a person.
In short, Hall describes her sacrifices of having to discard many of the pleasures of her conspicuous spending lifestyle.
That lifestyle is so far removed from the desperate struggles of survival so many face. It may be an unfair comparison, but I have often wondered similar thoughts about the differences in the day-to-day realities faced by Gov. Raimondo, her administrative team, as well as many of the reporters who have been busy covering her daily news briefings, and how far removed they are, frankly, from the struggle of survival facing many of Rhode Island’s most vulnerable residents.
For all the frequent expressions of empathy, the "haves" are still getting their weekly paychecks; they still have health insurance coverage through their jobs; they are not facing eviction or foreclosure or repossession of their vehicles. Indeed, some can tweet about the pleasures of social distancing with Zoom cocktail hours with relatives.
Call it a major disconnect.
PROVIDENCE – For some seven years, I have had an ongoing dialogue with Dr. Peter Simon, a retired pediatrician and epidemiologist, on all things considered related to health, health care, health equity and place-based health.
What I have learned, in part, from the conversations, is that Dr. Simon speaks in plain English, in understandable phrases, which in our current times of a bewildering pandemic, can offer a refuge from the “expertise” that all too often dominates our airwaves.
His recent posts on Facebook have attracted a devoted following of “friends” who ask him questions that he then attempts to answer. His straight-ahead approach has provided guidance during a time when it is difficult to navigate through the maze of conflicting messaging.
His observations, in ConvergenceRI’s opinion, offer a common-sense approach that is often missing from the pronouncements of many experts and analysts. Translated, what Dr. Simon says is easy to comprehend. It carries with it a tone of voice he says he developed in working with patients for decades, a kind of direct, verbal honesty.
In an earlier story, “Late for the sky,” ConvergenceRI used some of Dr. Simon’s analyses, often taken from his Facebook posts, as a starting point to conversations about how best to frame answers to the perplexing questions around the coronavirus. [See link to story below.]
Consider one his more recent Facebook posts: “As Rhode Island increases the volume of tests being done, we will see the marginal increase in new cases fall. As we increase volume, the rate of detection will approach the true rate of infection in the population at large.”
Now is the time, Dr. Simon continued “to allocate testing to a random sample of people in Rhode Island who have not already been tested. Without this, we continue to fly blind. Evaluating our control and containment efforts will be impossible without population-based testing.” Makes sense, doesn’t it?
ConvergenceRI asked Dr. Simon to stitch together an analysis of where we currently are – and where we need to go – in planning our future strategies to cope with COVID-19, in advance of a vaccine in 14-18 months. The questions to prompt the discussion included: What is needed in terms of testing? How long will we be required to maintain social distancing? What is the best way to begin reopening the economy?
Here are Dr. Simon’s common-sense answers.
ConvergenceRI: What are the determinants we need to pay attention to?
SIMON: We are hearing increased talk about health disparities. Answering questions about such disparities can provide some context to the daily death toll [from coronavirus] being reported by Gov. Raimondo and her team.
For example, there are questions from reporters attempting to understand why Rhode Island deaths in nursing homes are so prevalent, compared to other states. Why does there appear to be a higher rate of infection for people of color, particularly for Latinos?
Age and poverty are two determinants that I hear used frequently; there is also talk about different levels of access to medical care.
I wonder if people really understand the complexities of underlying measures that exist in real time for these complex relationships.
Let’s think of the roof on your house. When after time the roof starts to leak, you call a professional roofer.
The roofer comes to your home, examines the problems with the old, worn roofing, and gives you options for replacing or repairing the roof.
What does the roofer know that makes him/her an expert? What is known is how roofs age and weather. Aging of roofs depend on their material’s resilience and tolerance of changes in temperature, rain/snow, etc.
How these materials weather will vary with the material that makes up the roofing.
The best materials weather better, last longer and cost more. The health of people is similar.
We are born into a genetic, socially variable environment. We all are born with varying predispositions for 30-40 ailments that eventually will lead to death.
Most of us are born healthy and over time, because of “weathering” different distributions of privilege or threats, our health status changes over time.
Some researchers use the term “life course.”
Listening to the reports of deaths daily, you will not hear much about the “life course,” inheritance, weathering, or how the poverty of opportunity can get under your skin and influence your health outcomes.
There is a high cost to lifetimes spent weathering the storms of health, social and economic disparities, in how it increases the daily burden of the allostatic load – the daily levels of stress our bodies endure.
ConvergenceRI: How would you reframe the questions around what is needed in terms of testing to reopen for business?
SIMON: We are so obsessed with increasing the volume of testing. I just wonder why we are not asking a more important question: What is the best way to use the testing we have to understand what the populations of infected, recovering and still susceptible people look like?
ConvergenceRI: Can you translate what you just said in the context of potential pathways to reopening up the Rhode Island economy?
SIMON: Here is a path to opening up Rhode Island for business. It is rough and won’t be easy. We are not even close to being ready, in my opinion.
When admissions to our ICU beds and intubations have gone down to a trickle and health care workers who have been sent home into quarantine due to exposure or illness with COVID-19 are ready to return to work, Rhode Island should be able to start opening some of its closed small businesses, with new guidelines to continue to restrict crowding and easy transmission of the virus.
Some have suggested a four-week period of low rates of new infections, hospitalizations and intubations.
Then the question will be: Where in Rhode Island are we most likely to see high rates of people recovering from infections, and determining whether they were symptomatic or asymptomatic infections.
A recent pilot study conducted by Massachusetts General’s Clinical Pathologists as reported by The Boston Globe describes a test for immunoglobulins, using a test very much like a pregnancy test, on a drop of blood.
In Chelsea, one of the places in Massachusetts with the highest rates of illness, the study showed that about 30 percent of people tested had antibodies to COVID-19.
A similar study is now underway in Germany of 3,000 households chosen at random in Munich, whose goal is to understand how many people, including those with no symptoms, have already had the virus, a key variable to factor into making decisions about publc life in a pandemic.
No one knows what level of protection these findings confer on the community, but it is a sign that in a month or so, repeating this testing might show a much higher rate.
Getting to 80 percent or greater [of the population having antibodies] might be a target close to what epidemiologists consider “herd immunity.”
So, to summarize, we need time for our health care workers to recover, and for our hospital ICU’s to decompress and recover from the flood of very sick patients.
We need a reliable test of immunity. We need a plan to randomly test enough people around Rhode Island to tell where communities are along the road to herd immunity.
Without that kind of regiment of comprehensive testing, regardless of what the models may or may not predict, we are flying blind into the mist of the virus, with the likelihood that a new wave of coronavirus infections may occur.
ConvergenceRI: How important is it to maintain a regiment of testing for infection and antibodies, even after an initial “all clear” has been sounded by the government?
SIMON: Let’s say we find that Olneyville and the South Side of Providence have 75 percent of a random sample of residents showing evidence of immunity to COVID-19.
Small business previously closed could be opened, with restrictions on the number of customers allowed to shop or eat at the same time, and all workers would be required to have evidence of immunity.
However, if after several weeks of relaxed restrictions, there are increasing volumes of sick people from this area who are requiring admission to hospitals, the restrictions currently in place would have to be reinstated until those indicators had returned to the lower levels prior to lifting restrictions.
In other words, there is the potential of off and then on-again restrictions, based on continued measurements of key indicators of community transmission, in the neighborhoods and communities under focus.
In looking at the most recent "yield" of testing curves, Rhode Island found more than 300 cases yesterday [as of April 17] and had to test 1,000 more people than when we detected the same number at the beginning of the month. As the yield of testing continues to drop, we will soon be able to shift some of the new testing capacity to random samples in targeted areas of the state. Sampling this way over time, i.e., every month a new sample in Olneyville, will give us a trajectory for loosening or tightening our social distancing protocols.
