Covid-19 – RMLombard physician perspective

July 30, 2021February 12, 2023

The Covid Vaccine Conundrum

The mantra has reached crescendo proportions, “Get vaccinated, get vaccinated, get vaccinated!!!!”, and, for many, advice that should be followed. But is it good for all? Now, before being accused as being an “anti-vaxxer,” I’m not. At the same time, however, should it really be a “one size fits all” recommendation? So here is my perspective.

To my simplistic thinking here in the U.S. there are two segments of population as they pertain to the vaccine:

Those vaccinated. I fall into this group as do my many family members and friends. From the CDC data from July 2021, approximately 69% of the adult population has been vaccinated, most fully, while others have received at least one shot (Pfizer or Moderna). Other sites (e.g. USA Facts, which accumulates data from 70 government sources) report the vaccination rate of the entire U.S. population as being lower. In the case of USA Facts the published rates are 57% of the population having had at least one dose of the vaccine while 50% of the population are fully vaccinated (data as of July 25, 2021). So next time you hear about an “x” vaccination rate ask yourself whether the rate refers to adults only or if it refers to the entire population. If the latter, then anticipate lower rates as children <12 years of age, comprising ~47 million individuals, are being included. I am confident the reader is aware that there is a raging debate regarding the advisability of vaccinating this group to begin with as there is good data showing that both the likelihood of infection is very low in this group as well as the likelihood of transmission to adults is also low.
Those not vaccinated which, in light of the above figures, means 31% of the adult population or 43-50% to the entire population. I’ve had questions about the breakdown of this unvaccinated group because I suspect that, if the group is taken as a whole rather than component parts, it keeps the unvaccinated numbers high which are then alarmingly reported on whatever news outlet(s) you choose to get your information.

So what could make up the component parts of the unvaccinated group? For me this would include: a) kids <12 years of age if the vaccination rate is referring to the entire population, b) those with a true medical contraindication to the vaccine, c) those with moral objections to the vaccine (e.g. since there were cells used from aborted fetuses in developing the vaccine [esp. J&J] a number of Catholics refuse to get the vaccine), d) those who don’t believe any vaccine is worthwhile or safe, e) those who don’t trust the system and never will, f) those with misconceptions (e.g. microchips, risk of DNA alteration) or concerns (e.g. adverse affect on fertility) and, finally, g) those who have had Covid and either have questions about, or refuse to get, the vaccine. It is in this last group that I feel faces the vaccine conundrum. More about this momentarily.

Why get a vaccine? To build up immunity to an infectious process that could have significant consequences if infection occurs. So in the case of Covid, as with other viruses, immunity to the virus can develop because one becomes infected, recovers, and generates antibodies via a robust immune response to subsequent infection (natural immunity) or though vaccination. Natural immunity to Covid encompasses an individual’s immune response is to all components of the virus (capsid [think of it as the “shell” of the virus] as well as the spike [those projections sticking out of the capsid shown in multiple illustrations]). With vaccination alone the immune response is generated to the spike only which, as the data show, can still provide a very high level of protection. Antibodies to these components (anti-N, referring to the capsid; anti-S referring to the spike) can be measured and tracked (seroprevalence). “N” antibodies alone only develop through natural immunity while “S” antibodies are linked to the vaccines and natural immunity.

There is widespread agreement that individuals who become infected with Covid can be symptomatic or asymptomatic. In light of this there has been a persistent question as to what percent of the population, whether from symptomatic or asymptomatic infections, has recovered, and now has immunity to the virus? One attempt to generate data to answer this question has been through the Nationwide Commercial Laboratory Seroprevalence Survey. As of mid-May 2021, positive “N” seroprevalence rates (implying natural immunity) in the 50 States has ranged from 2.7% (HI) to 36.7% (OH) overall, with 25 states having rates <19%, 20 states 20-29%, and 5 states with rates >30%. The data, however, has been tempered by less than robust testing in some of the states. It was also not clear to me how the data breaks down between symptomatic/recovered and asymptomatic/recovered individuals. Overall, however, I think it is safe to say that there is a significant part of the population (depending on the State where they live) who has developed a natural immunity to the virus.

Now onto the conundrum. The conundrum faces those who have developed natural immunity (knowingly or unknowingly) to the Covid virus. Simply stated, it revolves around the question as to whether or not unvaccinated, but previously infected, individuals should get the vaccine. Those urging this subpopulation of individuals with natural immunity to Covid to get vaccinated do so for a variety of reasons some of which are: a) the duration of natural immunity is unknown, 2) potential side effects from getting the vaccine are uncommon (“rare” per CDC), and 3) it reduces the risk of reinfection. There are a few observations I would like to make.

Regarding duration of immunity–there are a growing number of studies showing that whether after Covid infection or vaccination the immune response is robust in most people. Ongoing studies also show that individuals with natural immunity still have immunity 12 months after infection while individuals who have been fully vaccinated have immunity at least to six months (discrepancy due to the fact that the virus has been around longer than the vaccines). It is unclear to me why those with natural immunity are being encouraged (and soon likely to be mandated) to get vaccinated. A few, of many, links: https://www.nih.gov/news-events/nih-research-matters/lasting-immunity-found-after-recovery-covid-19; https://www.nature.com/articles/s41590-02109233; https://clarion.causeaction.com/2021/07/28/johns-hopkins-physician-the-power-of-natural-covid-immunity/

Potential side effects–I agree statistically rare but tell that to the young adult, for example, who has developed myocarditis as a result of vaccination. Since it is understood in the scientific community that those in younger age groups (<40) often contract Covid but are asymptomatic, how clear is it that the vaccine is being given to someone in this age group with natural immunity especially when there has been concern expressed about the risk (regardless of age) of causing serious side effects? (Noorchashm, Hooman. “A Letter of Warning To FDA And Pfizer: On The Immunological Danger Of COVID-19 Vaccination In The Naturally Infected.”)

Reinfection–so reinfection in an individual who has received the vaccine is unfortunate but acceptable but not for one who has natural immunity?

I leave you with this final question and thought . Leaving aside the naysayers/doubters who will never be convinced, should unvaccinated individuals of any age group, but especially younger age groups, be given the opportunity to have Covid antibody titers checked periodically? If positive and high what is the advisability then of following (“natural history” in the science world) vs. forcing a needle into their arm at the risk of being considered a pariah otherwise? The science could be better. And, lest we forget, the vaccines are allowed to be administered under “emergency use authorization (EUA)” only (implying that the FDA isn’t totally comfortable with the safety and/or efficacy data). So, to me, those adults who have never been infected or are vaccine naive should strongly consider getting vaccinated especially if they have risk factors. Those who have developed natural immunity should have a choice.

Below are three links for additional review:

https://www.msn.com/en-us/news/politics/vaccines-benefit-those-who-have-had-covid-19-contrary-to-viral-posts/ar-BB1fZrwb

https://www.news-medical.net/news/20210608/No-point-vaccinating-those-whoe28099ve-had-COVID-19-Findings-of-Cleveland-Clinic-study.aspx

If You Had Covid, Do You Need the Vaccine?

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, can be found with “search” or, for some, just scroll down the page.

June 1, 2020June 11, 2020

Rationing in the Age of Covid…and other thoughts

I was still in practice in 2009 and played my critical care physician role in treating patients as part of the H1N1 swine flu pandemic. I do not recall issues as much as they pertain to personal protection equipment (I believe supplies were sufficient) but, as a tertiary care center, our institution was inundated with transfer requests for critically ill patients requiring use of a very sophisticated type of ventilator called an oscillator. Our supply was limited as were the respiratory therapists who could run them and so many transfers were denied once all our oscillators were in use. Regarding the oscillators the biggest hurdle I can remember was knowing how many were available at any one time and, fortunately, once the problem was realized, it was quickly solved. I never recall having a conversation with, or hearing discussions about, anyone in my group of 16 critical care physicians regarding rationing the use of an oscillator. The approach was one of “first come, first serve” when an oscillator became available; otherwise patients remained supported by a “standard” ventilator (patients rarely, if ever, went directly to oscillator support) or not accepted in transfer. Fortunately the pandemic subsided and all was (relatively) quiet until the Covid-19 pandemic began its assault on the world.

For a brief time, although it seemed like an eternity to patients and those in the healthcare system, Covid-19 had the potential to overwhelm the system with escalating rates of infection, available healthcare personnel, lack of PPE, and an ever increasing concern regarding the dearth of ventilators and how to ration those that were available. It is to this last point upon which I wish to give my perspective.

Rationing has always been part of healthcare whether we like it or not. For example, drugs or testing (try spending countless time on the phone with insurance companies, Medicare or Medicaid or with “peer to peer” to get something approved for a patient) are often regulated [rationed] by criteria set forth by the “powers that be.” But let me emphasize, there are criteria, no matter how well formulated or stupid, that are utilized. This brings me round to the early discussions regarding potential ventilator rationing if a hospital does not have the the capacity to meet the demand. Once that tsunami of Covid-19 infections hit, physicians and hospital systems worldwide came to the stark realization that there wasn’t enough–not enough PPE, staff, effective treatments, ICU beds, ventilators and…time. Time to think, to take a breath, to make a thoughtful decision knowing its profound consequences on life or death. At that time physicians did their best, decisions made, with the post-mortems of those decisions to follow. Currently the tact being taken is the formation of hospital committees in which rationing criteria are discussed, agreed upon, periodically modified and made available to physicians to help them in their decisions regarding situations where ICU care or ventilator rationing needs to occur. So, what would some of the criteria be?

Age was one of the first criterion to be considered. Why? Based on early data (see graph below) from China it appeared to be a no-brainer; older folks had higher mortalities thus leading to consideration of picking a certain age above which rationing would be considered and/or implemented. Several weeks ago I read a well written thoughtful article by a 70 year old author from the Hastings Center who, in his discussion regarding a particular age cutoff, opined that 70 years would be acceptable. His rationale? Data showed that deaths began to especially spike at age 70, that the older generation had to give the younger ones every opportunity, and he felt that he had lived a good life and would have been willing to forgo ventilator or ICU care if it meant potentially saving someone younger. However, controversy by that time had already arisen about using age as the sole criterion for rationing.

Fortunately, not soon after mortality data by age was published, wiser heads prevailed by asking, “What, other than age, affects mortality associated with Covid-19?” The answer, comorbidities, those chronic conditions or diseases that may be found in any age group resulting in less than optimal health. Listed in the below table are the comorbidities reported early in the pandemic. The developing rule of thumb–the more comorbidities one has, especially, but not exclusively, coupled with increasing age, the more likely of dying from the virus. Later on, morbid obesity and other comorbidities (see bottom of NYC table further on in blog) were added. The coupling of age with comorbidities has lead to subsequent formulation of healthcare guidelines in different settings regarding those situations where physicians and others were faced with the prospect of denying ICU care or ventilator utilization.

Significant (P <0.5) comorbidities complicating Covid-19 infection

Now, with using age coupled with comorbidity, a better perspective of how this combination can provide an evolving overview of the stratification of patient groups as it pertains to dying from the virus. A snapshot of this can be seen in the following chart:

provided by New York City Health as of April 14:

AGE	Number of Deaths	Share of deaths	With underlying conditions	Without underlying conditions	Unknown if with underlying cond.	Share of deaths of unknown + w/o cond.
0 – 17 years old	3	0.04%	3	0	0	0%
18 – 44 years old	309	4.5%	244	25	40	1.0%
45 – 64 years old	1,581	23.1%	1,343	59	179	3.5%
65 – 74 years old	1,683	24.6%	1,272	26	385	6.0%
75+ years old	3,263	47.7%	2,289	27	947	14.2%
TOTAL	6,839	100%	5,151	137	1,551	24.68%

[1] Underlying illnesses include Diabetes, Lung Disease, Cancer, Immunodeficiency, Heart Disease, Hypertension, Asthma, Kidney Disease, and GI/Liver Disease. [source]

As I studied the above information what struck me was the number of patients without a comorbidity in the: a) 18-44yr age range who made up 8% of the cohort deaths but only represented 0.4% of total deaths, b) 45-64yr age range who made up 3.7% of the cohort deaths but represented 0.9% of total deaths, c) 65-74yr age range who made up 1.5% of the cohort deaths but represented 0.4% of total deaths and d) 75+ yr olds who made up 0.8% of the cohort deaths but represented 0.4% of total deaths. The obvious conclusion is that few of us get into our older years without experiencing some kind of comorbidity. The second obvious conclusion is that increasing age plus comorbidities increased the likelihood of death from the virus. The less obvious conclusion, however, is that if one gets into their older years without any comorbidities, then the risk of dying from the coronavirus is the same as those without comorbidities who are younger or much younger. This, then, circles back to the argument using age as the sole criterion for rationing; it should not.

Let’s now put the information above to the test. Here are several scenarios I’ve envisioned, but have not specifically read or heard about. You are the critical care or ER physician on duty and are faced with the following two patients, both with Covid, both with respiratory failure, both need ventilator support, BUT…there is only one ventilator. Decide between one or the other or…neither: I) an 18 year old male otherwise healthy or an 84 year old man with COPD and hypertension, II) a 42 year old morbidly obese man with hypertension and diabetes or a 75 year old woman otherwise healthy, III) a 38 year old woman with advanced cancer or a 73 year old woman with diabetes and hypertension, IV) a 68 year old man with COPD and hypertension or a 72 year old woman with diabetes and chronic heart failure, V) a 38 year old man otherwise healthy or a 76 year old man with hypertension, diabetes, and asthma who happens to also be a noted public figure, VI) a 72 year old woman with chronic heart failure, diabetes, and hypertension or a 72 year old man with chronic heart failure, diabetes, and hypertension.

Did you choose wisely or not at all? The one not chosen may not have thought your choice wise at all. Understand that the guidelines put in place by hospitals all anticipate physicians having time to discuss them with a patient and/or family in those critical decision-making situations. If the clinical status of an already hospitalized Covid patient deteriorates to the point of needing more critical care, then there is a relative “luxury” of time to review guidelines with all involved and make decisions no matter how positive or negative they may be. I suspect that if the 70 year old Hasting Center author was hospitalized with Covid there would be a welcome discussion of the guidelines and most likely a decision not choose ventilator support based on his previous opinion. What if there was no time for discussion, for example, two critically ill Covid patients arriving in an ER at the same time? What if the patient and/or family don’t agree with the guidelines and want “everything done”? While not with Covid, I have encountered the latter in previous clinical situations and leads to an incredible amount of stress for all involved.

There are a few final thoughts on a slightly different, but related topic, having to do with elective surgeries or procedures. I can understand the closing of these in light of the real concerns about the virus overwhelming our health care system. There was a need to divert supplies (e.g., PPE, ventilators), nurses, and at least some physicians (e.g. anesthesiologists) until we could have a better idea of how things were going to play out. Screening protocols and testing needed to be put in place. However, in my opinion, the return to elective surgeries or procedures has been too slow. Any surgeries or procedures done at least at a free standing surgery center could have resumed several weeks ago. Unfortunately the next few months will give us a better picture of the likely non-Covid mini-epidemic of missed cancers, delayed non-cancer diagnoses, and delayed corrective therapies leading to prolonged suffering.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, can be found with “search” or, for some, just scroll down the page.

April 9, 2020April 26, 2020

Covid-19 and HIV

A few weeks ago one of my brothers texted me–“Can you liken this to anything in your career [as a pulmonary critical care physician]? I guess HIV-AIDS…” My immediate response was “no” in light of the different viruses but as time went on, and with further reflection, I came to the realization that my career had been bookended by two viral pandemics both of which were approached in very different ways. Here is my perspective.

The Acquired Immune Deficiency Syndrome, most commonly referred to as AIDS, reared its ugly head in the early 1980’s. As a third year resident (1983) I remember reading a detailed article about it in the “Annals of Internal Medicine.” Unusual diseases (pneumonia, parasitic infections, uncommon cancers) were cropping up in a segment of the population defined as “the 4 H’s”–homosexuals, hemophiliacs, heroin addicts, Haitians, with the largest group at that time being homosexuals. While the diseases were recognized as manifestations of what appeared to be an altered immune system, no specific underlying cause of this alteration was known at that time although a viral etiology was suspected. Also, it was not totally clear how easily or by what means the underlying cause for AIDS could be spread. Blood and semen appeared to be logical conduits for transmission in light of some of the affected populations but what about saliva? or a sneeze? or a cough? or sweat? What was your risk for developing AIDS if an AIDS patient scratched you or if you just accidentally stuck yourself with the needle you just pulled out of the arm of one of these patients? If you were infected with whatever was the presumed causative agent, but not manifesting and AIDS symptoms, what was the risk of passing the agent on, for example, by swimming or playing sports (especially contact sports)?. All unchartered territory.

As a pulmonary fellow I held the distinction (I think) of being the first physician at our institution to bronchoscope a presumed (subsequently confirmed) AIDS patient. He was a homosexual, freshly arrived from the baths of San Francisco, who, when respiratory symptoms began and after being informed by a physician there he likely was developing an AIDS illness, decided to come back home to Pennsylvania not by plane but by car. While he phrased it more crudely than what I write here he explained that by traveling this way it gave him the best opportunity to spread as much love as he could across the nation. In light of a constellation of symptoms and an abnormal chest x-ray, the infectious disease docs wanted tissue confirmation of a pneumonia. Hence the bronchoscopy. I asked my Chief what precautionary measures we (he, and others, would be in the room with me) should take. He didn’t know. With a little literature digging I found an article suggesting what might be appropriate to wear while bronchoscoping an AIDS patient. As I was the primary bronchocopist extra protection was recommended. My attire on the day of the bronch included a lead apron first (we needed fluoroscopic {x-ray} guidance when doing the lung biopsies), head covering, double gowns and gloves, mask, and goggles. I could barely move. One of the RT’s snapped a picture (Polaroid) wearing my finest and for years the picture hung in the RT break room as “AIDS patrol.” Little did I know that I, as well as everyone else, had just been introduced to what in later years would be called “personal protection equipment” (PPE)–minus the lead apron.

One of the tenets in Infectious Disease mitigation in time of widespread infection is quarantine. This was a hotly debated topic at that time but eventually was not pursued out of concern that a quarantine would drive infected people “underground”and away from healthcare. So, what were the treatment options at that time? Very limited; mainly symptomatic relief with an occasional respite from a particular type of pneumonia affecting AIDS patients with use of a sulfa based antibiotic. In essence, an AIDS diagnosis was a death sentence.

Government and the healthcare system, slow at mobilization at first (read, “And the Band Played On”), eventually began to ramp up. The human immunodeficiency virus (HIV) was ultimately found to be the underlying cause of the immune system dysfunction. Over time it became apparent that one could have the virus (HIV+) and be totally asymptomatic. Only when a person developed manifestations of disease related to immune deficiency was the term “AIDS” applied. So asymptomatic HIV+ patients could spread the virus (e.g. blood, semen, vaginal or rectal fluids, needles) and never manifest an AIDS scenario. One of the saddest cases I knew about was of a young mother who developed AIDS after she was infected by her HIV+ husband who “played both sides of the street” and never let her know. Since one did not know who was HIV+ a universal premise in hospitals was established–assume everyone was infected. Thus the advent of “universal precautions.” This lead to the routine use of gloves when dealing with patients and establishment and ongoing refinement of disposal policies for needles and other “sharps”, soiled bandages and blood products. Protocols for dealing with a healthcare worker injured by needles or other sharps were developed and refined.

Universal precautions eventually became standard everywhere and remain in place today. Screening of blood donors took on a new aspect with a pre-donation questionaire given to all. One of the questions, controversial at the time, inquired if the donor believed they were in one of the risk groups (the 4 H’s) or engaged in activities which might place them at risk for an HIV infection. If the answer was “yes” the policy was to let that person leave with no further questions asked. In sports protocols were established to deal with a bloodied player. For example, basketball games would be stopped briefly so that a player displaying a bloody (no matter how minor) injury could leave the court to be treated (note the gloved trainer). The use of PPE (gloves, gowns, face shields, masks, head/foot gear) also became standard and was tailored to the type of patient being cared for, with gloves always the minimum requirement.

A breakthrough in testing for HIV occurred in 1985 with development of ELISA assays. Now that there was a way to “track” the virus, drugs related to treating the underlying HIV infection could begin to be developed. Testing improved over time as did drugs for the treatment for HIV+ patients with the goal to suppress/destroy the virus in an effort to maintain a healthy immune system thereby preventing the development of AIDS. Anti-virals appeared in the late 1980’s and were continued to be refined over the ensuing 10-15 years. Different drugs in different combinations (“cocktails”) came to the forefront with greater and greater success at treating the infection. For a growing number of people the specter of the inevitability of AIDS was no more as, if the virus could be suppressed, the immune system would remain intact.

Now to present day and the coronavirus, aka “Covid-19”. Did the approach to HIV give us a “leg up” in dealing with this current pandemic? Undoubtedly these are different viruses with different manifestations of infection and contagion. However, I think there are several observations which can be made.

1) Testing–AIDS was the visible result of an HIV infection but it would take time before HIV was recognized as its cause since genomic testing was in its infancy. In light of the explosion in genomic testing since then the coronavirus genome was mapped within the first month or so of the first patient becoming symptomatic.

2) Contagion–Early in the AIDS epidemic, before HIV was discovered, there was a large degree of uncertainty regarding the ease of contagion. In time it became apparent that asymptomatic HIV+ patients could not spread the disease just by being, for example, on a cruise ship or plane or where there are/were large social gatherings. Now as we are more and more a global society the coronavirus spreads much more easily, especially since early warnings were not forthcoming (China) or played down (WHO) or response times were slow (many governments), thereby giving it a “head start.” The coronavirus contagion shares this similarity to the influenza virus of 1918 in contrast to HIV.

3) Personal protection equipment (PPE) and Universal Precautions–as noted above had its beginnings with the AIDS epidemic. As I look at pictures of those currently decked out in their PPE, I often think about that “AIDS patrol” picture taken long ago.

4) Treatment–“social distancing” is the phrase of the day and the strategy appears to be working. But don’t fool yourself, this is about as close to a quarantine as one can get short of utilizing the true draconian measures that have been periodically used in times past. However, social distancing, i.e. avoidance, isn’t treatment in the true sense of the word. That’s where drugs and possibly plasma infusions come to the forefront. Recall that drugs to treat HIV took years to develop and numerous trials before released to the public. Currently there are several drugs, both antibiotics as well as anti-virals, being investigated. The debates rage–compassionate use? seat of the pants? trials?–as the debates did then for HIV. Currently there are more options being looked at than ever were in the early days of HIV.

5) Prevention–there are no vaccines for HIV but there is hope and expectation that sometime within the next 12-18 months there will be a vaccine for the coronavirus. The rapidity with which efforts are being made to this end are breathtaking. What has yet to be answered is whether the vaccine will offer “once and done” protection or will it be like the influenza vaccine where yearly “boosters” are required. And what about the anti-vacciners? (As an aside, I recently spoke with an older woman who says she NEVER gets a flu shot but would consider getting a coronavirus “shot”).

6) Unknowns–we’ve had 40 years to “work out the kinks” regarding HIV and the knowledge base is solid. Not so with the coronavirus. How long can a patient infected with the virus remain contagious? Outside of the 14 day “window” will there be asymptomatic people who could be carriers for extended periods of time? With recovery from infection is there immunity and is it transient, lifelong or something in between? Will the coronavirus take its place along side influenza as a seasonal recurring infection? Will the virus play along with the rules of “herd immunity”? What is the true infection rate as many people infected with coronavirus will remain asymptomatic?

Lastly, but as importantly, is the economic effect. HIV never affected the economy to any large degree, let alone shut it down. Covid-19 obviously has and to potentially devastating effects. While not able to contrast HIV/Covid-19 in this light, I wondered about the 1918-1919 influenza pandemic–were there economic parallels? If you are curious I refer you to a very interesting paper (written for the layman), “Economic Effects of the 1918 Influenza: Implications for a Modern Day Pandemic,” by Thomas A. Garret, written in 2007. The link is: www.stlouisfed.org/…research-reports/pandemic_flu_report.pdf (or Google or Bing it). To me it was an eye-opener as to how that pandemic was eerily similar in many, but not all aspects, of what we are seeing today regarding urban vs rural mortality, density population mortality, white vs non-white mortality, age mortality, and effects on local, as well as the national, economy. And, once the pandemic abated, this paper points out that overall economic recovery was rapid for most. Hopefully this will be the same this time.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions can be found with “search” or, for some, just scroll down the page.