Infectious Disease Update

Yes, I too have the seen the news reports, Horizon Scanning Hypothetical Reader.

Including the reports of overwhelmed hospitals and clinics in China over the last month, prompting WHO questions and investigation.

No, none of that is reassuring. China does not have the best reputation for transparency in the best of times. A rigid political system that will game statistics and information released to the public for its own ends in the best of times does not inspire trust. Especially when this is the same administration which decided it had “solved” COVID twice before– first with totalitarian and prolonged lockdowns until open revolt seemed imminent, followed by a head-spinning volte-face to open wide the COVID doors and take the substantial health hit in one large go. But most especially because this is the same administration that exacerbated SARS-CoV-2’s emergence with a slow recognition of the initial problem and deliberate obfuscation of the extent of the problem. If there was ever a chance to contain SARS-CoV-2 and prevent the pandemic, China fumbled it for internal political reasons.

I will grant the window to contain SARS-CoV-2 was narrow, and the virus may well have been out before anyone knew it was there. That is the very best that can be said of China’s initial approach around this time four years ago. (yes–four years now!)

But hey–at least you have the WHO, which was also less than forthright in the initial outbreak and seemed focused far too much on placating China. In the WHO’s defense, they are an intergovernmental organization with no real enforcement capabilities which must rely on co-operation of host nations to manage global health problems. They are also entirely funded by what are, in the end, voluntary contributions from global governments. These limitations are structural, and cannot be avoided by the WHO. They are baked in, integral. The WHO will always play politics to some extent because it must. Do not expect the WHO to do otherwise, and there has been no meaningful reform to these structural impositions on the WHO since the pandemic most clearly exposed them. Nor can there be, unless the WHO were to somehow become self-funding or part of a world government with actual enforcement capability. As far as the WHO goes, “great technical work and advice coupled with, and limited by, political necessities for its funding and ability to operate in hot zones” is simply the hand we are dealt.

Practically speaking, that means when China says “no unusual pathogens” in the rash of respiratory diseases flooding their hospitals, and WHO says “we agree with China” — well, there’s a certain level of skepticism to those statements going forward.

“Trust, but verify” comes to mind.

So the good news is that preponderance of evidence aligns with the WHO here. China was late to the re-opening party from the pandemic. Arguably the last country to end strict social distancing and mask measures. The experience of every other country in the world, after Omicron waves were subsiding and restrictions were lifting, was that the very next winter brought a spike in RSV, influenza and omicron cousin COVID, all at the same time. Pediatric populations whose exposure to things like RSV and flu would typically have been spread over several seasons got condensed into one high wave. You even saw scare headlines of the “triple pandemic,” sure to force new lockdowns etc. etc. Until everyone remembered that winter was normally when all of these respiratory things tended to hit hard, and we managed.

In short, China is absolutely due for their own triple pandemic, where ALL the cold/flu like things come roaring back in a winter of discontent. This because social distancing for COVID also hammered down all of these bugs. Since they have been muted a few seasons, there is not much herd immunity to them out there.

I say this is most likely what is going on for a few China and WHO independent reasons. First, let’s assume something novel–some new fresh infectious hell, lurching inexorable towards us survivors of this decade, still desperately clutching flotsam in the chaotic waters around us. If that is true, it was already flooding ERs in China. Based on the SARS-CoV-2 experience, that new monster is already out. Guarantee it. You have multiple patient zeros in multiple countries spreading it right now.

Which means… we should be hearing about that. Multiple countries should, by now, be reporting a sudden influx of cases in clinics and hospitals with respiratory symptoms, but negative for the usual suspects, including SARS-CoV-2.

That is not happening. Instead, the curious incident of that dog in the night is that, as in the Sherlock Holmes’ story, it ain’t barkin’.

Second, where we do have increases in respiratory diseases presenting, and that includes the US at the moment, they are all demonstrably due to known causes. You are seeing the typical seasonal uptick in flu, colds, RSV, and yet another omicron descended COVID variant whom I will not name. Hospitalizations from all of these are up, including COVID, but the COVID variant is still another “less severe, more contagious” version. All of these we can treat.

What is proliferating out of all of this?

Scare articles.

You’ll see headlines about a sudden spike in “white lung syndrome” or “white lung pneumonia.” I have no idea what that is, and neither do the authors of these articles. All they are describing is the pattern one sees in any general lower respiratory infection, where fluid and immune cells entering the lungs cause the lungs to look a little more opaque on a chest x-ray. “Opaque” on an x-ray is “white.” So it looks like lungs are a snow globe that has been shaken a little. All of these, even a good chest cold, will cause that chest x-ray appearance. That’s not a more severe or dangerous pathogen on the loose, causing this crazy new syndrome.

You will also have seen headlines about some of the cases in China being due to an increase in mycoplasma pneumoniae infections, and how there are also new outbreaks of myco pneumoniae being reported in some European countries, Ohio, and I believe Massachusetts if I’m remembering a headline a week or two ago correctly. Regardless, near as anyone can tell, these aren’t even the same strain of myco pneumoniae. Just coincidental upticks in a common, known pathogen that typically hits kids (and some adults) around this time of year too.

“Wait,” I hear you say Trivia Night Dominator Hypothetical Reader, “isn’t Mycoplasma pneumoniae that bacteria most famous for NOT having a cell wall like every other bacteria?”

Yes! That’s right! What a remarkable bit of trivia to have remembered from that med micro class so many years ago Hypothetical Reader. The reason that trivia is significant is that, as a bacteria, Mycoplasma pneumonia is very treatable with antibiotics. However, several entire classes of important antibiotics work by targeting bacterial cell walls–so only part of antibiotic armory will work on these bacteria, since they have no cell to target!

“I knew that was important for a reason,” you say Hypothetical Reader. “I bet I can guess the disease this bacteria causes from its name alone!”

I bet you can too, Hypothetical Reader. Go for it.

“St. Vitus’ Dance.”

Exactly! Mycoplasma pneumoniae causes “atypical” or “walking” pneum– Wait. Did you say St. Vitus’ Dance?

“I did.”

The outbreak in the Middle Ages where patients would compulsively dance for hours until they collapsed from exhaustion? That St. Vitus’ Dance?

“Yes.“

Not known to be associated with Mycoplasma pneumoniae, at least as far as I can tell. The cause of St. Vitus’ Dance is still debated. Among the better theories are a manifestation of ergotism, thus basically a psychologically active version of St. Anthony’s Fire. Mass hysteria has also been blamed. There are even theories, and I swear I am not making this up, that St. Vitus’ Dance were all staged, and thus really the very first social mob dances to ever go viral. Even with social media, there is nothing new under the sun.

“It happens to me when my favorite T Swift jam drops in the club.”

I’m going to pretend that you are not comparing Taylor Swift to a still mysterious psychological affliction historically affecting great masses of people so that we can still stay friends, Hypothetical Swiftie Reader.

Anyways, as you might infer from the name, Mycoplasma pneumoniae causes pneumonia. Typically a very mild version of pneumonia called “walking pneumonia” since patients are rarely hospitalized. Thus, walking around with it. It’s also called atypical pneumonia because the symptoms are a low grade fever and a dry cough, typically a persistent cough lasting longer than a cold that comes in spasms. In the long long ago, when I was on a peds and family medicine rotations, the soft sign was a cough that come in bursts, and end sound like the kid was nearly about to throw up from the coughing. It usually clears itself–otherwise, antibiotics can be given as mentioned above.

The sudden, headline creating jump in cases? In Warren County, Ohio, among the hardest hit thus far, you’ve gone from ~20-ish usual cases of myco pneumoniae this time of year to 140. Yeah. That’s your jump right there.

This isn’t a pandemic of cell wall-less bacteria sweeping the globe.

Now, before you ask Hypothetical Reader, could something novel be lurking, simmering among all of these other cases? Yeah, it’s possible. If it was more severe, with pandemic potential though, it should be announcing itself by now, as a growing proportion of these cases that are testing negative for all the usual suspects. Again, that’s not happening, so the chances of this are quite low. I’ll keep an eye on it, but I don’t think the sequel to SARS-CoV-2 is coming to theaters this year.

There was a prolonged Hollywood strike after all…

In other health news, did get forwarded an article on an uptick in anthrax cases in Africa. Again, this does not appear to be a burgeoning pandemic. Instead, early indications are that sustained high food prices globally due to inflation have been pushing more people to go hunting. Anthrax spores can live in soil for a long time, up to decades under the right condition, and anthrax is endemic in animal populations in many parts of the world. Including parts of the US and Canada. Also does not appear to be related to bioterrorism, which is always a thought with anthrax (the inhaled version is -very- dangerous). An estimated 1.83 billion people live in regions with high endemic anthrax risk; even then, cases are typically pretty low, usually skin infections (not inhaled spores) and you’re only talking low thousands across Africa right now. An anthrax pandemic, as an exciting new spin-off series of the SARS-CoV-2 pandemic, is also NOT coming to screens near you this winter, or this year.

Mini-Ramble

“I’m not seeing any of those ‘2024 is going to be my year’ posts… guess y’all have finally learned your lesson.“

Chanced on that meme the other day. Intended as a joke, like some of the best humor, there is disquieting truth behind it.

The soft signs abound, still. From the subtle, like the aggressive, inconsiderate driving everywhere. That has somehow become worse this year. Even accounting for the usual increase this time of year. Everyone is rushing through a holiday to do list, everyone is in a hurry, but the night comes early and because everyone has a list, the traffic is just that much worse. That annual dance of the rush to get everything done before everyone is off at work, all around the same travel/shopping/”holiday cheer’ needs. I wonder if in some ways we don’t create the need for the break we hand ourselves between December 25th and January 1st.

There is hard data too. Car repo rates and lending on the cars that are getting repo’d are looking very similar to subprime housing a few years back. Cost of daily necessities is up something like five fold from 2019. In the United States, 62% of people are living to paycheck to paycheck. Globally, setting aside the headline manmade and natural disasters, food prices are as high, on a relative basis, as they were in 2008. I congratulated our South African correspondent on South Africa’s win in the rugby world cup a few months back — a very close game against the New Zealand All Blacks. Aside from the commentary on the game, the comment that stuck out was along the lines of “thanks–South Africa desperately needed some good news this year…”

So it’s not just you. And it’s not just where you live.

This odd malaise seems to be spreading.

As another soft example, this has been the wildest year in Human Resources I can personally remember. I wonder if you have seen it too. In fact, I know some of you have. I have heard, or seen, more “bait and switch” job and promotion offers. Ridiculous low ball offers. Companies so eager to prove they are totes not racist that they arranged for a minority candidate to speak with only other minority interviewers–even if the role those employees held had nothing to do with the job the candidate was seeking. No, I’m not making that one up. You can also look up any number of articles from this year “explaining” why the interview process now takes 4-6 months, with as many 17 separate interviews (since you are scheduled to talk to everyone during those rounds), and with the expectation that you will take off from your current job to jump those hoops. That process can only select for two categories of employees: 1) those who have been out of work for 4-6 months and have the time to jump through those hoops and 2) those desperate enough to go through them. Yes, those categories can and do indeed overlap.

Just in medicine, I have been contacted by more former residents/fellows this year from my training about how to leave medicine, perhaps for industry. Current residents have pinged me too, as an alum. Half of my residency class already no longer practices clinical medicine. Found out half of the physicians in my wife’s endocrine fellowship class or their also internal medicine derived physician spouses no long practice clinical medicine either.

I find that trend worrying too. But I understand. One of our friends here is now in a mostly administrative role with a major health care center. We were killing time before the kids’ Christmas program recently. He seized the opportunity to tell me, urgently, the business degrees are running these healthcare systems, and run them as business. Which means patient care quality and patient dignity are sacrificed as a trade-off to business optimization.

Tough to not be a little wry here. This was new to him. An “epistemiological shock” as the cool academic kids call it.

For one of his examples, surgery, cardiology and oncology are viewed as profit centers by the business degrees he works with. I don’t doubt that. But to his horror, it meant the ability to get resources for any other specialty–for new facilities, upgrades, proper staffing–was all but nonexistent. Everything else is a cost center, and costs must be reduced. There are mathematically sound economic formulas that say so.

The greatest success in medicine is achieved when the patient no longer needs you. For that reason, medicine run as a business, which implies the relentless search for new “customers” (by definition, patients with a significant health problem) and to expand services/products at a quality “customers” will accept, delivered at a price that generates profit, is different the medicine optimized for patient outcome. The incentives and goals do not always align properly.

That misalignment may be getting worse.

Half of my class no longer practices clinical medicine, and the list of those seeking to leave or already out is accelerating. We’re the mid-career demographic, where we have just enough youth and just enough experience to be at our most effective, most productive.

That’s when they are choosing to leave. That’s a problem.

Stated overtly or couched in the epistemiologic shock of how the system really runs (now that we are moving into positions that expose us, like my new administrator friend), the reason is the same.

I go back to the pandemic. Testing for the state was long hours, on a system we were holding together with duct tape. Every day, even on the weekends. Morale never suffered. Those were easy hours to put in. Because the medicine was clear, the purpose was obvious, and we were committed to it. We were letting schools stay open. Fire houses stay staffed. Little old ladies at high risk of severe COVID kept safe until treatments were available. The medicine was pure. Same as when I get calls from friends and family about various maladies, or stopped by guys at the gym for the various bumps and brusies.

That’s why we all joined. But no one wants to be Anthony Hopkins in “Remains of the Day”, trapped by sentiments of duty in service to a cause that is not worthy of the sacrifices it takes. The epistemiologic shock that the incentives of the system are misaligned to the ideal of medicine is causing many to worry that if they are not careful, they will waste the remains of the day in service to something other than what they should.

Nor is it just the doctors. There have been several massive unionization drives for nurses, arguing that the system and its chronic understaffing (gotta’ keep costs down) is jeopardizing patient care for executive bonuses. Some for physicians too.

Perhaps the biggest tragedy is that the profit focus isn’t even working. Many hospital systems, academic and private, are running in the red — or taking in less money than in previous years. Which means the economics training of the MBA administrators in these systems will only encourage them to double down on cost cutting, and focusing on specialties and areas that are reimbursing relatively well. Which will only cause more despair, quiet and overt quitting, burnout, and unionization.

I am also sure you see echoes of this in your own professions. What is striking to me this year, talking to anyone about their work, is the pervading sense that everyone is just trying to get by. Putting on the mask, doing the duty. But behind it is a sadness. Some inexplicable sense that it’s not right, and that they too sense that incentives are misaligned somewhere in what they do.

Perhaps that is why “Corporate Erin” has gone viral, capturing the all too obvious response of the soulless corporate/institutional process to this malaise.

“Send the middle managers, the vice presidents, the CEOs to the all hands and the meetings to say that things that even they do not believe.”

At least in the past we could be fooled sometimes; even more rarely, we actually had leaders who really did believe, and saw people for people. Instead, there seems to be a mass resignation of everyone, from leaders on down, to this malaise. We pretend like we’re not all secretly wondering if we, too, are sqaundering the remains of the day. We pretend like the pretending we see in others, like Corporate Erin, works.

Meanwhile, we seem to have selected for those who can tolerate the cognitive dissonance best. Who can say things in service to the institution or company that they think others want to believe, even when the actions of individuals and institutions demonstrably do not meet those words. Who can best pretend that no one else can see they are pretending.

And they select for the desperate with the many HR sins of the year. The bait and switches. The “how many hoops will you leap through” selector for how desperate you are.

How best to create those so desperate they will pretend along. Squander the remains of the day, because they feel they have no other choice.

This malaise has been so pervasive I was sent the famous Henry David Thoreau quote by a young man in his 30s. He had lost sleep the three previous nights, worried that Thoreau was right, and that all he could reasonably look forward to was the same life of quiet desperation he increasingly saw around him.

I’ll expand on my response to him here.

Thoreau believed he saw shallow lives, pursuing the trivial, and lived in fear. Thoreau found this fear contemptible. For what the masses clung to was paltry, seeking to hold what little they appeared to Thoreau to have, lest they lose what Thoreau judged was no great loss at all. Shadows on the wall of a cave, unworthy of the importance the desperate masses esteemed them, even unseemly in the moral compromises that some of them made to keep their illusions.

“Once in a Lifetime” and “You Can Call Me Al” were better treatments of middle and upper class midlife angst.

Regardless, Thoreau condemns himself in his statement far more than he condemns those he judged living quiet, desperate lives. For Thoreau spectacularly failed to see the myriad of stories around him. He saw only the outer life that everyone was living. That’s what a popular culture is. What he missed is that the desperation is not for loss, not about clinging to a life not worth living, or being afraid to take risks. No, what he missed is that into every life, no matter how humble, there is at least one moment of great crisis. A moment of moral choice, where your true values will be revealed. Every life has that moment — if you could ask them all. And if they would answer honestly and truthfully about it.

Take a surprisingly poignant episode of “The Simpsons” for example. Homer gets out of the drudgery of his dead end job working for Mr. Burns. He gets his dream job at the bowling alley after a lot of sacrifice and planning. Less pay than the nuclear plant, but he was excited. Better hours, less stress, something he found more fulfilling. Then he finds out Maggie Simpson, the baby, is on the way. The dream job is no longer enough. He has to go back to the nuclear plant, and live what Thoreau would call a quiet, desperate life. Mr. Burns forces him to hang a placard where he will see it every day that reads “DON’T FORGET: YOU’RE HERE FOREVER.” The episode ends with Homer telling Bart that Maggie’s pictures are not in the family album because Homer puts them where he needs the most — the plaque at work:

The question is not if you are desperate, but what you are desperate for.

Indeed, a man wiser than I looked at desperate people — the poor in spirit, the meek, those seeking justice, the merciful, the pure of heart, the peacemakers and the persecuted — and called them all blessed. For what they were desperate for was worth the price they were paying. Further, those who persisted towards those goals would achieve them.

Homer’s quiet desperation is not wasted — seen in it’s full context, it is a noble sacrifice for another that Thoreau, in his conceit, does not see.

If anyone was caught looking at the superficial, and not the deeper, it was Thoreau.

The crime is not that the masses are desperate — for I suspect most, if not all, are desperate for noble and worthy causes. Makes it easier to forgive the Corporate Erins when I hear them in real life, or the pickup truck doing something dangerous and stupid for that one extra car length in traffic.

No, the crime is the indignities, the pretendings they endure for that cause. The misalignment of incentives they cannot change. That we somehow keep creating and fostering systems that produce these indignities, and force hardship on others, is the crime.

We seem cursed to make our choices harder than they should be — and then judge ourselves harshly for those choices.

What a mad world…

I was reminded as well of Plato’s allegory of the Cave. I hadn’t thought much about it since undergrad really. For a brief refresher, if you need one, Plato in his “The Republic” is writing after his Greek society has killed Socrates, his teacher, for the “crime” of pointing out the hypocrisies of that society, endeavoring to change them. Pointing out the pretending, the malaise, the way the society was creating criminal hard choices and desperate lives too. Plato is arguing that wiser leadership is needed, a different system of government, but cannot do it directly. He manages to arrive at a philosopher king — convenient, for a philosopher, but the lament for wiser leadership of human societies has been so persistent through the ages that his words are still translated and read to this day.

Regardless, in the cave are citizens, chained to the cave floor, and watching images projected onto the wall in front of them, believing that to be real life. Of course, it’s not. One day, one of the citizens gets loose (Plato called this a philosopher), and sought to free the others from their chains and lead them out to real life. The irony is that some of the citizens, knowing nothing else, prefer the illusion. They even become hostile to those trying to loosen the chains, stop the movie, and lead them to the light!

There are a number of allegories here, but I certainly forgot that at its core, at the time of its writing, this was about Socrates. Plato is being indirect, using allegory, lest the ruling class realize he is criticizing them and kill him like his teacher. That’s the context in which it was written.

The context in which I was reminded of the allegory of the Cave pointed out a couple other threads I didn’t catch in my early 20s. First, how often those who would speak this kind of truth to power must so often resort to indirect, allegorical means. Another prime example is Jesus, as the vast majority of his moral teaching was delivered as parables. Aesop and his fables. The Tao Te Ching is anything but direct. How odd that obvious moral truths, the desperately wanted virtues we largely all agree on, must be communicated indirectly. How ironic how often they meet with hostility, even when they do take the Socratic, or allegorical routes. With particular hostility to those threatening to seriously live those virtues. Secondly, I was reminded that the allegory of the Cave presupposes that there is someone chaining the citizens to the cave and projecting images they know to be false. Someone who already knows reality, but does not wish to share it with the others. If we are being generous, that party may be motivated by knowing the truth is far more awful, and perhaps the projections are a pleasant fantasy. Like Santa Claus for young kids, or “The Matrix” for older ones. Alternatively, they distract with the falsehoods and protect the chains to keep advantages for themselves by knowing what is really going on.

Yes, I know, this does set up nicely to the weary dread of another US election season. Now with AI, and already two very different movies on two very different screens.

That said, the last part I find most interesting about the allegory of the Cave is the same observation I have for Thoreau’s “quiet, desperate lives” quote. There is a bit of Lake Woebegone effect when you read these, isn’t there? Much like the 80% of drivers who believe themselves to be “above average”, we read the Cave and we read Thoreau, and thoroughly convince ourselves that we one of those few who will see past the images, and break free of the chains, and avoid the curse of the masses with anything but a quiet, desperate life. I include myself here, don’t worry! Even in believing in my above average driving, despite knowing what the probability really is : )

Conceit is contagious. Just ask the Thoreau I have pilloried in absentia thus far.

I suppose the only way to know for sure is to not assume that you are free of your chains. Nor assume that you are seeing the light in the cave, the true reality, and not still watching a very convincing movie. Especially since you are now, conveniently, the hero of this story! There is no narrative more compelling than that, and if there is a movie to show you on a cave wall to distract you, one that paints you as the wise hero acting benevolently is a great choice.

Avoiding that bias will take questioning even beliefs you like and cherish and are sure of now. That is a damn hard thing to do. The other way, I suppose, is to know what you are desperate for, lest you, too, squander the remains of the day.

And remember, where Thoreau forgot, that others have a deeper story than you are seeing. We usually interact with only the public life of one another. The circle of those who see our private, or secret lives, is much smaller. You can safely assume others you interact with are watching different different projections on the wall. Some may in fact be seeing a true light, and you are still watching projections, without realizing it! Keeping the thought that story goes deeper than you know, for all around you, and that we are all, overwhelmingly, desperate for similar things, and value similar, if not identical, virtues. And that we share the same weaknesses.

There’s a good quote by an AI ethicist out there who pointed out that social media algorithms are baby AI, and conquered our attention not by being clearly smarter or better, but by amplifying human weaknesses in dopamine — which can be driven just as effectively by outrage, sexualization etc.

There were also some fire quotes I came upon over the year about evil. I don’t recall all the sources, and I am probably paraphrasing a few, so forgive my lazy scholarship on these, but they are worth sharing:

“Evil is when something internal or external prevents a creature from fulfilling its sacred purpose.”

“Rare is the person actually trying to do evil. They do exist, but they are more rare than you think. The banality of evil is that everyone is trying to do good, but everyone’s definition of good can be a little different by virtue of culture or circumstance. Or they select a strategy with unintended consequences. Everyone is seeking the best life for themselves, and others they cherish.“

The banality of evil is what creates the banality of Corporate Erin.

Regardless, keep all of this in your heart in 2024. Because I think we can all feel that 2024 will be the nadir, in a decade where a century will happen. Everyone will be seeking the best life for themselves — but incentives are not aligned, and some will choose very poor strategies, with unintended consequences.

This is the decade when we get tested, my friends. I don’t remember the source of this quote either, and I know I am paraphrasing, but we are not sent tests that we should fail them. Tests are also a chance to show what we are truly capable of doing.

If you train to climb a mountain, practice and learn the techniques, but never actually go to a mountain and climb it — how will know if you really could? There is risk there. Danger. Discomfort. Climbing mountains isn’t easy.

To continue to flog this horse, this decade, this test, comes at time in life where we are not yet old, but wiser than we were when we were young. Generations turn their eyes to us now. This time is our test.

This coming year, clear your heart, clear your mind. Step away from the screens–allegorical and literal. Take deep breaths first.

Counsel patience. Counsel peace.

The test is coming, and that strain will certainly make these feel like desperate times.

So be desperate — as long as you are desperate for.

Time to show what we can do…

Happy Holidays,

Paladin

P.S. When you hit the dog days between Christmas and New Year’s, and are looking for something well worth your hour, you can catch this must watch presentation from another angle on the state of AI and where it is going here or the updated version on Spotify where these speakers were invited on the Joe Rogan Experience. The latter will be updated with the huge strides in AI in just the intervening six months between them.

Meanwhile, your moment of Zen: