Parents know that winter is the season of sickness. Your kid will have approximately infinite colds. You, too, will have approximately infinite colds. Last winter, COVID precautions kept sickness at bay. But this year, school is in session, day-care colds are spreading fast, and the only cohort of people in America not yet eligible for COVID vaccination is our youngest children. Aside from promises of clinical-trial data by the end of the year, the timeline on which children younger than 5 might be vaccinated is still unclear. The parents of these kids are staring down months more of carefully weighing the risks of COVID against the benefits of indoor cheer. My own child, now 20 months old, was born in March 2020, so my entire experience of parenting has been pandemic-inflected. As the cold creeps down the East Coast, where I live, and nudges the people around me inside, I have been thinking about how the responsibility and anxiety of navigating around this one infectious disease might linger longer for the parents of small children than for most other Americans. Some days, the idea that my family will still have to be making these calculations far into 2022 feels impossible to grasp. How can it be that even after two years, I won’t be able to meet my friends and their kids at the aquarium, or a museum, or a pizza place without dedicating brain space to what we’re all risking? How are other parents handling this? As cases rise again and the season of sickness sets in, I asked that question to a small group of my Atlantic colleagues:
All of us live in New York City or Washington, D.C.—places with high vaccination rates—and, as Atlantic employees, we’ve all been able to work from home throughout the pandemic. All of our kids are, for at least part of the week, going to school or day care (at least until an inevitable fever triggers pandemic-era policies that require kids to stay away and get tested for COVID). All of us understand that the risk of healthy kids getting severe COVID is relatively low, but we are still limiting our activities to some extent. As a rule, we avoid taking our kids to busy indoor places, and we’re generally still choosy about whom we invite over. We were joined by Natalie Dean, a professor of biostatistics and epidemiology at Emory University, who specializes in infectious-disease research and has, herself, a 4-year-old and an almost-2-year-old. What follows is a transcript, edited for length and clarity, of our conversation about the risks we’ve taken, the risks we might take, and the pressing questions we now have about America’s approach to childhood sickness. Sarah Laskow: I’m curious: What would change anyone’s COVID calculus at this point? For those of you with older kids, does having them vaccinated change anything at all? Daniel Engber: My daughter had her first dose of the vaccine and is going to get her second dose in a couple of weeks. I got really excited about the idea of let’s set up new rules for the family. And then we realized we didn’t even have clearly delineated old rules. I feel like some of our attitudes are shifting toward thinking about the state of community transmission—so if we come up with some new rules now, will they look different in a month if case rates are shooting up in New York City? That feels much harder to do. It’s a lot easier to think in terms of which or how many of us are vaccinated than to start thinking about these moving targets. Do we want to look by city, or county, or borough, or state? National rates? What should we be keeping track of? Or should we stop keeping track of anything and kind of abandon rules altogether? Laskow: It seems to me like a lot of parents are thinking that way. Well, once my kid is vaccinated, then I can change my behavior. Short of that, I don’t know what to do. Julie and I both had kids right at the beginning of the pandemic, and I wonder, for you, Julie, is there anything short of your child getting vaccinated that you think would change your behavior at this point? Julie Bogen: There was very briefly a period over the summer when people were getting vaccinated and mask mandates were still in place in Montgomery County when we were like, Oh, maybe we’ll take her to the grocery store. But right now, in part because of my husband’s job as a doctor who treats COVID patients, but also because of the notion of, like, Okay, well, if we do take a risk, and she gets sick or her day care closes, that’s another 10 to 14 days I have to be out of work, the disruption is so significant. Also I feel so paralyzed by judgment of other people and parents if we were to get sick. You know, like, Oh, you guys got COVID? Do you know how you got it? Did you do something irresponsible to get it? I really can’t think of anything short of my daughter getting vaccinated that would change our behavior right now. I feel like I don’t know how to not blame myself if something went wrong. Laskow: Natalie, does the availability of vaccines for older kids matter in any of these calculations? Natalie Dean: Having the older kids vaccinated does matter in the sense that kids have a certain set of people they interact with, and that includes older siblings. Just having fewer opportunities for the family to be impacted by needing to isolate or quarantine, that will certainly help. Older kids are also just a big chunk of the population that will be less likely to get infected and less likely to transmit once they’re fully vaccinated. But it’s going to be a long time, maybe never, that we’re going to see case rates really go to zero. I think we just need to be realistic about that—this virus is going to continue to circulate for a while. I also wanted to make a comment about this stigma. Because of the nature of the pandemic, there’s a lot of stigma about transmission, and I think we’re going to need to move past some of that as well. There’s not the same stigma about RSV or flu or these other respiratory pathogens, and they cause a pretty similar risk to kids. That would be another thing that, as we move forward, we need to grapple with. Becca Rosen: I’ve been trying to make the case among my friends and to colleagues that getting COVID is not a sign of personal failure. We live in a society with illness, and we don’t blame people when they get flu. We have to learn to not see getting COVID as a moral failure. Because this is something we have to live with, and the truth is that we will all be exposed. [Read: America has lost the plot on COVID] To tie that into what Julie was saying, the practical disruption of a COVID infection to people’s lives is so much worse than with RSV or with flu because of the policies we have in place. So it seems like we’re in a spot where we really, really do need to update our policies for a COVID-endemic world. Especially with our testing infrastructure still really dysfunctional, even testing negative to return to school after a COVID exposure can mean days out of work for a parent. For a lot of parents, that’s just not tenable. Dean: Part of living with the disease, too, is improving testing infrastructure in the way that we really need to get it to work. It doesn’t mean that testing needs to go away, but that it needs to be strengthened. Engber: I feel like when my older daughter is fully vaccinated, it increases my urge to ignore or subvert some of the policies. I just wonder if other parents have had that thought too. Like, if she’s fully vaccinated and has a stuffy nose and it might be allergies, am I going to really adhere to the rules of her school’s screening process? I feel my attitude toward the policies and their legitimacy is changing in real time. Rosen: I think the policy sometimes discourages people from testing. Because they don’t want to wait on a result or risk getting a false positive, which is just totally a perverse outcome. Bogen: Especially because the tests take so long. And my daughter’s day care doesn’t want her to come in if she has a pending COVID test. We test every time we go to our parents’ houses in Connecticut, for example, and because she has a pending test, we’re not supposed to send her. And it’s like, now we just don’t want to tell you. Laskow: How is everyone thinking about your responsibility to the other kids and parents in collective situations? If your kid is going to day care or school, do you think about what you could be bringing to that space? Or is it more about keeping your own family protected? Nick Catucci: I am on the knife edge, sending my daughter to day care five days a week, between being incredibly resentful every time she catches a cold from some other kid and then being like, How in the world am I not going to send her to day care today, even though she has the sniffles? And so I just rely on the school to tell me. We would never send her to school with a fever, because that’s one of the rules—a fever is really the only thing that excludes you. But she has had a runny nose and a cough for months, basically, and we just live with that. In my building, you have to put on a mask coming in and out of the building. And for my daughter … I just don’t. I flout it for my daughter. I don’t make her put a mask on for the two minutes that we’re walking to the elevator and taking the elevator up and going into our apartment. I put it on. And I am very pro-mask, but part of me is like, Why are we still doing this? I know a lot of people in this building are vaccinated. This seems silly. Laskow: I think part of what we’re circling around is this dynamic—Sarah Zhang wrote about this in an Atlantic article recently—that because we don’t have an agreement anymore about what the overall goal for COVID management is, we don’t have a shared set of rules that we’re moving toward. What I hear in this conversation is the frustration among people who have been taking COVID precautions and getting vaccinated and who are now running up against the limits of what’s possible with that. Rosen: My memory of being a new parent, for both kids, who were pre-pandemic babies, is that we were just sick all the time. There wasn’t the level of disruption to our lives now required by the policies of day cares and schools for testing and quarantining and everything—but it was still hugely disruptive. So I’ve just been thinking about the question of work and how, across society, we need to have better sick-leave policies to deal with not just COVID, but the childhood viruses that kids get all the time. How can we update our thinking about parenthood beyond the first couple of months of life to be more aware of the illnesses that kids and parents deal with? And how can work and school and all these other institutions that we interact with build illness into our real understanding of what people’s lived experiences are? Engber: Before the pandemic, there was the same kind of stigma and anger. I would feel like, So-and-so went to a birthday party with coxsackievirus, what a jerk. This heightened care that we’re taking with children—are there good parts of that, that should persist when the kind of acute phase of the pandemic is over? And what should that new normal look like for how cautious we are with our kids and infectious diseases? Laskow: I think my biggest question is: How much should I worry about my kid being an agent of spread as an unvaccinated person, given how many people around her are vaccinated? What is our responsibility as parents to other people, to keep our kid from infecting them? And then, what’s society’s responsibility toward us, as parents? Bogen: Right—what do we owe other people, given that they’re the ones who are vaccinated while our children are not? I still don’t know what I owe my own child, given that her risk is so low. I’m doing everything I can to protect her. My husband and I are doing everything we can to protect the people around us. But, you know, we’re both vaccinated, and we’re still avoiding going to the grocery store with her. We still don’t eat indoors. We still see so few people. Are we missing out on huge areas of life and sanity restoration for nothing? I just don’t know. Laskow: Natalie, given that we’re moving toward endemic COVID, is there a certain point when parents should shift their thinking about any of this? Or what’s the point at which we can stop thinking about this at all? Dean: When will we stop being able to think about it at all? That might be a ways off. I think that there is going to be this new normal that will involve some level of different procedures for day cares and kids around all illnesses. I really do weigh, if the situation is not going to change that quickly, what am I willing to add back to my life that I think is valuable? Of course, we should acknowledge people who have children who are immunocompromised—that requires really working out a plan with their specialists and requires a different set of considerations. But for otherwise healthy children, because the risks remain low, I want them to be able to have some fun. And so I’m letting them have playdates, for the most part still outdoors. But when the weather is yucky, it can be indoors—we have been doing maskless play dates with one other family. My thinking has shifted to a longer time horizon, because this is going to stick with us for a while. I don’t want to wait forever to resume some of those things. Laskow: I think that ultimately that is the challenge of being a parent in the pandemic. It’s been a long, long time now, and we want our kids to have lives. And if they don’t experience things now, then they won’t experience them at that time in their life, which is a pretty intense calculation in the end. Rosen: Yeah, I mean, it really gets me, what my daughter went through when she was 5. We basically cut off all her closest friendships for months on end. And I think friendships at that age are so formative and so foundational to who you become. I think kids deserve a lot at this point. They’ve been through a lot. My daughter will say to me, “Your childhood was so special because you don’t have to deal with a pandemic.” My 7-year-old articulates that. She gets what she’s been through and how abnormal and hard it was. from https://ift.tt/3FUzalh Check out http://natthash.tumblr.com
0 Comments
As fall dips into winter in the Northern Hemisphere, the coronavirus has served up the holiday gift that no one, absolutely no one, asked for: a new variant of concern, dubbed Omicron by the World Health Organization on Friday. Omicron, also known as B.1.1.529, was first detected in Botswana and South Africa earlier this month, and very little is known about it so far. But the variant is moving fast. South Africa, the country that initially flagged Omicron to WHO this week, has experienced a surge of new cases—some reportedly in people who were previously infected or vaccinated—and the virus has already spilled across international borders into places such as Hong Kong, Belgium, Israel, and the United Kingdom. Several nations are now selectively shutting down travel to impede further spread. For instance, on Monday, the United States will start restricting travel from Botswana, South Africa, Zimbabwe, Namibia, Lesotho, Eswatini, Mozambique, and Malawi. It’s a lot of news to process, and it comes without a lot of baseline knowledge about the virus itself. Scientists around the world are still scrambling to gather intel on three essential metrics: how quickly the variant spreads; if it’s capable of causing more serious disease; and whether it might be able to circumvent the immune protection left behind by past SARS-CoV-2 infections or COVID-19 vaccines, or evade immune-focused treatments such as monoclonal antibodies. All are risks because of the sheer number of mutations Omicron appears to have picked up: More than 30 of them are in SARS-CoV-2’s spike protein, the multi-tool the virus uses to crack its way into human cells—and the snippet of the pathogen that’s the central focus of nearly all of the world’s COVID-19 vaccines. Alterations like these have been spotted in other troublesome variants, including Alpha and Delta, both of which used their super-speedster properties to blaze across the globe. (Omicron is only a distant cousin of both, not a direct descendant.) If--if—Omicron moves even faster than its predecessors, we could be in for another serious pandemic gut punch. [Read: The coronavirus could get worse] But it’s way too early to know if that’ll be the case. What’s known so far absolutely warrants attention—not panic. Viruses mutate; they always do. Not all variants of concern turn out to be, well, all that concerning; many end up being mere blips in the pandemic timeline. As Omicron knocks up against its viral competitors, it may struggle to gain a toehold; it could yet be quelled through a combination of vaccines and infection-prevention measures such as masks and distancing. Vaccine makers have already announced plans to test their shots’ effectiveness against the new variant—with data to emerge in the coming weeks—and explore new dosing strategies that might help tamp down its spread. Omicron might be set up for some success, but a lot of its future also depends on us. To help put Omicron in perspective, I caught up with Boghuma Kabisen Titanji, an infectious-disease physician, virologist, and global-health expert at Emory University. Our conversation has been lightly edited for clarity and length. Katherine J. Wu: Why don’t we yet know for sure how worried we need to be about Omicron? Boghuma Kabisen Titanji: What we do know about the variant is this: Some of its spike-protein mutations have been seen in other variants and other lineages described earlier on in the pandemic, and have been associated with increased transmissibility and the ability of the virus to evade the immune response. What we don’t know, and what is really hard to predict, is what the combination of mutations will do together. This particular variant now appears to be outcompeting other circulating variants in South Africa—there have been these clusters of cases. That is actually what led to this variant being identified in the surveillance systems that they have in place there. That raises the concern that the variant is more transmissible or may be escaping the effects of the immune response induced by vaccines or infection from earlier strains. But we really don’t know that for sure yet. [Read: Coronavirus variants have nowhere to hide] The disconnect is this: The surveillance systems have worked exactly in the way they are designed to. It makes us know what to look out for. However, when these systems pick up a signal, we don’t immediately get the epidemiologic data we need to know all of the impacts a new variant can have. That takes time. Right now, we have a limited number of [viral genomic] sequences, and a limited number of cases. Now the alert is out. People will start looking for this new variant, not only in the countries that initially reported on this, but now worldwide. There’s now a search to make sure this variant is well-characterized. That’s when we will gain a better understanding of whether it’s causing more severe disease, how much it is escaping immunity, and how transmissible it is. It’s important to keep in mind that other variants of concern have emerged before, including immune-evasive variants like Beta, which was first identified in South Africa, but eventually petered out. Wu: Could we have seen the arrival of Omicron coming? Titanji: Viruses are going to evolve regardless of what we do. There are things we can do to slow that down: barrier measures [such as masking], vaccinating. And there are things that we can do that can maybe speed up or aid the evolution of the virus. One is if we’re not doing what we need to do to prevent spread of the virus within the population. Every time a virus spreads, it gets another opportunity to infect a new host, and it gets another opportunity to evolve and change and adapt. All of this means that it is worth having a conversation about whether the slow rollout of vaccines globally has had an impact. In certain parts of the world, not enough people have been given a measure of protection to allow them to be able to withstand infection, and to slow down transmission of the virus. Are we actually giving the virus an opportunity to spread unrestricted in certain places and drive its evolutionary trend? It’s basically exposing ourselves to the emergence of more variants. So this was predictable. If the virus has the opportunity to spread unchecked in the population, then we’re giving it multiple ways in which to evolve and adapt. If we had ensured that everyone had equal access to vaccination and really pushed the agenda on getting global vaccination to a high level, then maybe we could have possibly delayed the emergence of new variants, such as the ones that we’re witnessing. Wu: We’re still dealing with Delta, a previous variant of concern. Where do we go from here? Titanji: A good place to start is reminding people that we are definitely not where we were two years ago, when SARS-CoV-2 emerged. We now have a better understanding of how the virus is transmitted from person to person. We have antivirals that are coming down the pike. We have a better understanding of how to manage and treat cases of people who do get infected. We have vaccines and incredible mRNA technology that allows us to adapt quickly to a changing virus, and we will have second-generation vaccines. It’s definitely not back to square one. [Read: Timing is everything for Merck’s COVID pill] Secondly, this does not mean that the vaccines that people have are now completely useless—the doses they have received are not null and void. We have not yet seen a variant of concern emerge that has been able to completely escape the effect of vaccines. The immunity from the vaccines may be less protective, which may translate into more post-vaccine infections from a new variant, if it takes off. But that is yet to be determined. We also know that a booster dose really does boost the antibody response. A new variant could dent the [protection offered by the immune system], but that usually happens in degrees. There is still going to be immune responsiveness from previous immunizations, and infections from ancestral versions of the virus. It may simply mean that you need more of those antibodies to be able to neutralize that new variant of concern. We also have T cells, which play a role, and may not be as impacted by the variant. [Read: The body is far from helpless against coronavirus variants] This variant could not have chosen a worse time to emerge. We’re in flu season. This is a time when respiratory viruses tend to spread quite efficiently. And we are in the holiday season, and there's a lot of traveling, and a lot of people getting together with family. But it’s certainly not the time for people to let their guard down, or relax on nonpharmaceutical interventions. People have to be mindful of wearing their mask when they’re out in public, or in crowded areas with people whose vaccination status they may not know. People have to be mindful of getting tested when they feel unwell, and isolating appropriately and doing all of those things that we have learned how to do over the course of the last two years, and that we know are effective in mitigating the spread of virus. The same measures will still work while we figure out just what this new variant means for us. Get your boosters. We’ll figure it out. Wu: Several countries instituted travel bans this week, many of them primarily focused on African countries, where surveillance systems detected Omicron not long ago. How big of an impact might that make? Titanji: Historically, there is a lot of evidence that by the time a travel ban is instituted, the virus has already gone … and potentially well beyond the borders of the countries that [the ban is] restricting travel from. Instituting travel bans as a knee-jerk reaction can send the wrong message to countries that are contributing to the global effort of virus surveillance. We could end up disincentivizing countries from reporting because they fear retaliation. There are other measures that could be taken to ensure that travel is safe. For example, to get an international flight, you have to be fully vaccinated as a requirement for most countries, or show proof of negative tests. We will be better served if we put the emphasis on the countries that have seen the highest number of cases of this new emerging variant: providing them with the resources to actually contain the variant, and making sure that they have the resources for testing, for isolating cases, for doing the science that we need to better understand Omicron. Wu: Some countries are already deep into their rollout of booster shots, and have, in recent months, lifted many restrictions; others are still barely making a dent in administering first doses. Regardless of where we go with Omicron, what does this say about our approach to COVID-19 as a global society? Titanji: What this reiterates is that the world is so interconnected. We are in a global pandemic, and we cannot address this fully if we only have regional solutions. The solutions really have to be with a global mindset. And that global mindset means that the resources we have—vaccination, testing, access to therapeutics, and also the support to carry out appropriate surveillance—need to be equally accessible and equitably distributed in all parts of the world. [Read: The fundamental question of the pandemic is shifting] We can’t leave people behind. The virus will catch up with us regardless of where you are, regardless of what country you’re located in. You may be fully vaccinated, you may have had your booster, but you’re not that disconnected from the person who lives in a country where only 2 percent of the population is vaccinated, and who doesn’t have access to any of the treatments. We need to have less of an inward-looking focus. Because otherwise we’re just going to prolong how long we stay in this pandemic. from https://ift.tt/3nYi5k9 Check out http://natthash.tumblr.com Before she caught COVID-19 at a wedding in March 2020, the physician associate spent her days diagnosing and treating people; after she was infected, she turned to her own colleagues for that same care. “At first,” she told me, “I felt a kinship with them.” But when her tests started coming back negative, her doctors began telling her that her symptoms—daily migraines, unrelenting vertigo, tinnitus, severe crashes after mild activity—were just in her head. (I agreed not to name her so that she could speak openly about people she still works with.) When she went to the emergency room because half her body had gone numb, the ER doctor offered to book her an appointment with a counselor. Another doctor told her to try removing her IUD, because, she remembers him saying, “hormones do funny things to women.” When she asked her neurologist for more tests, he said that her medical background had already earned her “more testing than I was entitled to,” she told me. Being part of the medical community made her no different from any other patient with long COVID, her eventual diagnosis. Despite being a physician, she couldn’t convince her own physicians—people who knew her and worked with her—that something was seriously wrong. I’ve interviewed more than a dozen similar people—health professionals from the United States and the United Kingdom who have long COVID. Most told me that they were shocked at how quickly they had been dismissed by their peers. When Karen Scott, a Black ob-gyn of 19 years, went to the emergency room with chest pain and a heart rate of 140, her physicians checked whether she was pregnant and tested her for drugs; one asked her if her symptoms were in her head while drawing circles at his temple with an index finger. “When I said I was a physician, they said, ‘Where?’” Scott said. “Their response was She must be lying.” Even if she had been believed, it might not have mattered. “The moment I became sick, I was just a patient in a bed, no longer credible in the eyes of most physicians,” Alexis Misko, an occupational therapist, told me. She and others hadn’t expected special treatment, but “health-care professionals are so used to being believed,” Daria Oller, a physiotherapist, told me, that they also hadn’t expected their sickness to so completely shroud their expertise. A few of the health-care workers I talked with had more positive experiences, but for telling reasons. Amali Lokugamage, an ob-gyn, had obvious, audible symptoms—hoarseness and slurred speech—so “people believed me,” she said. By contrast, invisible, subjective symptoms such as pain and fatigue (which she also had) are often overlooked. Annette Gillaspie, a nurse, told her doctor first about her cough and fast heart rate, and only later, when they had built some trust, shared the other 90 percent of her symptoms. “There was definitely some strategy that went into it,” she told me. For other medically trained long-haulers, the skepticism of their peers—even now, despite wider acknowledgment of long COVID—has “been absolutely shattering,” says Clare Rayner, an occupational physician who is part of a Facebook group of about 1,400 British long-haulers who work in health care. “That people in their own profession would treat them like this has led to a massive breakdown in trust.” Having dedicated their working lives to medicine, they’ve had to face down the ways its power can be wielded, and grapple with the gaps in their own training. “I used to see medicine as innovative and cutting-edge, but now it seems like it has barely scratched the surface,” Misko told me. “My view of medicine has been completely shattered. And I will never be able to unsee it.” Medical professionals have a habit of treating themselves. Daria Oller, the physiotherapist, was following her training when, after she got sick with COVID, she pushed herself to exercise. “That’s what we tell people: ‘You have to move; it’s so important to move,’” she told me. “But I kept getting worse, and I wouldn’t acknowledge how poorly I was responding.” She’d go for a run, only to find that her symptoms—chest pain, short-term-memory loss, crushing fatigue—would get worse afterward. At one point, she fell asleep on her floor and couldn’t get back up. At first, Oller didn’t know what to make of her symptoms. Neither did Darren Brown, also a physiotherapist, who tried to exercise his way out of long COVID, until a gentle bike ride left him bedbound for weeks. He and others told me that nothing in their training had prepared them for the total absence of energy they experienced. Fatigue feels flippant, while exhaustion seems euphemistic. “It felt like someone had pulled the plug on me so hard that there was no capacity to think,” Brown said. “Moving in bed was exhausting. All I was doing was surviving.” But these problems are familiar to people who have myalgic encephalomyelitis, the debilitating condition that’s also called chronic fatigue syndrome. Physiotherapists with ME/CFS reached out to Oller and Brown and told them that their symptom had a name: post-exertional malaise. It’s the hallmark of ME/CFS and, as that community learned the hard way, if you have it, exercise can make symptoms significantly worse. Brown has spent years teaching people with HIV or cancer about pacing themselves, mostly by divvying up energetic tasks throughout the day. But the pacing he needed for his post-exertional malaise “was totally different,” he told me. It meant carefully understanding how little energy he had at any time, and trying to avoid exceeding that limit. Brown, Oller, and other physiotherapists with long COVID co-founded a group called Long Covid Physio to discuss what they’ve had to relearn, and they’re frustrated that others in medicine are still telling them, people whose careers were built around activity as a medical intervention, that long-haulers should just exercise. Ironically, Brown told me, doctors are loath to prescribe exercise for the HIV and cancer patients he regularly treats, when clear evidence shows that it’s safe and effective, but will readily jump on exercise as a treatment for long COVID, when evidence of potential harm exists. “It’s infuriating,” he told me. “There’s no clinical reasoning here.” Neither Brown nor Oller knew about post-exertional malaise or ME/CFS before they got long COVID. Oller added that she initially thought little must have been written about it, “but no, there’s a whole body of literature that had been ignored,” she said. And if she hadn’t known about that, “what else was I wrong about?” Long COVID has forced many of the health-care workers I interviewed to confront their own past. They worried about whether they, too, dismissed patients in need. “There’s been a lot of Did I do this?” Clare Rayner told me, referring to the discussion in her Facebook group. “And many have said, I did. They’re really ashamed about it.” Amy Small, a general practitioner based in Lothian, Scotland, admitted to me that she used to think ME/CFS symptoms could be addressed through “the right therapy.” But when Small got long COVID herself, some light work left her bed bound for 10 days; sometimes, she could barely raise a glass to her mouth. “It was a whole level of bodily dysfunction that I didn’t know could happen until I experienced it myself,” she said, and it helped her “understand what so many of my patients had experienced for years.” ME/CFS and other chronic illnesses that are similar to long COVID disproportionately affect women, and the long-standing stereotype that women are prone to “hysteria” means that it’s still “common to write us off as crazy, anxious, or stressed,” Oller said. This creates a cycle of marginalization. Because these conditions are dismissed, they’re often omitted from medical education, so health-care workers don’t recognize patients who have them, which fuels further dismissal. “No one’s ever heard of POTS at med school,” Small told me. (POTS, or postural tachycardia syndrome, is a disorder of the autonomic nervous system that is common in long-haulers.) It doesn’t help that medicine has become incredibly specialized: Its practitioners might have mastered a single organ system, but are ill-equipped to deal with a syndrome that afflicts the entire body. Health-care workers were also overburdened well before the pandemic. “People with chronic disease need time to really open up and explain their symptoms,” Small told me, and health-care workers might be able to offer them only a few minutes of attention. “Because we work in a stressed system, we don’t have the time or mental space for those diagnoses that don’t have easy answers,” Linn Järte, an anesthetist with long COVID, told me. At worst, the pressure of medicine can sap the clinical curiosity that ought to drive health-care workers to investigate a set of unusual symptoms. Without the time to solve a puzzle, you can quickly lose the inclination to try. Those puzzles are also extremely challenging. Small remembered talking with patients who had ME and “seeing this multitude of issues that I couldn’t even begin to scratch the surface of,” she told me. Her frustration, she imagined, must have come across to the patient. Admitting to a patient that you don’t have the answer is hard. Admitting it to yourself might be even harder, especially since medical training teaches practitioners to project confidence, even when in doubt. “It’s easier to say This is in your head than to say I don’t have the expertise to figure this out,” the physician associate told me. “Before COVID, I never once said to a patient, ‘There’s something going on in your body, but I don’t know what it is.’ It’s what I was trained to do, and I feel terrible about it.” Over the course of the pandemic, waves of frustrated, traumatized, and exhausted health-care workers have quit their jobs. Several long-haulers did so because of the way they were treated. Karen Scott, the ob-gyn, left medicine in April even though she is now well enough to do some work. “Ethically, I couldn’t do it anymore,” she said. Alexis Misko told me that returning to the profession would feel “traitorous”, and besides, she cannot. She hasn’t been able to leave her house since December 2020. Other long-haulers have lost their jobs, their homes, or even their lives. Those who recovered sufficiently to return to work are getting used to wearing two often-conflicting mantles: patient and physician. “We’re go-getters who made it to this point in our careers by getting through things at all costs,” Hodon Mohamed, an ob-gyn, told me. Even if health-care workers wanted to rest, medical shifts are not conducive to stopping and pacing. Annette Gillaspie, the nurse, still struggles with about 30 symptoms that make bedside nursing impossible; she’s back at work, but in a more administrative role. And the physician associate is still working with some of the same colleagues who belittled her symptoms. “There are people whom I don’t refer patients to anymore,” she told me. “I have a cordial relationship with them, but I won’t ever view them the same.” As the pandemic progressed, health-care workers have felt more and more exhausted and demoralized. They’ve been overwhelmed by work, disaffected with their institutions, and frustrated with patients. These conditions are likely to exacerbate the dismissal that long-haulers have faced. And many health-care workers remain ignorant of long COVID. Meg Hamilton, a long-hauler, a nurse, and (full disclosure) my sister-in-law, told me that most of her co-workers still haven’t heard of the condition. Recently, a colleague told her that a patient who was likely a long-hauler couldn’t possibly have COVID, because the disease’s symptoms don’t last past a month. As a recent nursing graduate, Hamilton doesn’t always have the seniority to fight such misconceptions, and more and more she lacks the energy to. “Sometimes I won’t even tell people that I had long COVID, because I don’t want to have to explain,” she told me. Others feel more optimistic, having seen how long COVID has transformed their own practice. Once, they might have rolled their eyes at patients who researched their own condition; now they understand that desperation leads to motivation, and that patients with chronic illnesses can know more than they do. Once, they might have minimized or glossed over unusual symptoms; now they ask more questions and have become more comfortable admitting uncertainty. When Small recently saw a patient who likely has ME/CFS, she spent more than half an hour with him instead of the usual 10 minutes, and scheduled follow-up appointments. “I never would have done that before,” she told me. “I would have just been afraid of the whole thing and found it overwhelming.” She and others have also been educating their colleagues about long COVID, ME/CFS, POTS, and related illnesses, and some of those colleagues have changed their practice as a result. “I think those who are transformed by having the illness will be different people—more reflective, more empathetic, and more understanding,” Amali Lokugamage, the ob-gyn, told me. For that reason, “long COVID will cause a revolution in medical education,” she said. But that future relies on enough medically trained long-haulers being able to work again. It depends on the health-care system’s ability to accommodate and retain them. Most of all, it hinges on other health-care professionals’ willingness to listen to their long-hauler peers, and respect the expertise that being both physician and patient brings. from https://ift.tt/3p2RT7A Check out http://natthash.tumblr.com In a world with perfect coronavirus tests, people could swab their nose or spit in a tube and get near-instant answers about their SARS-CoV-2 status. The products would be free, fast, and completely reliable. Positives would immediately shuttle people out of public spaces and, if needed, into treatment; negatives could green-light entry into every store, school, and office, and spring people out of isolation with no second thought. Tests would guarantee whether someone is contagious, or merely infected, or neither. And that status would hold true until each person had the chance to test again. Unfortunately, that is not the reality we live in—nor will it ever be. “No such test exists,” K. C. Coffey, an infectious-disease physician and diagnostics expert at the University of Maryland, told me. Not for this virus, and “not for any disease that I know of.” And almost two years into this pandemic, imperfection isn’t the only testing problem we have. For many Americans, testing remains inaccessible, unaffordable, and still—still!—ridiculously confusing. Contradictory results, for instance, are an all-too-common conundrum. Cole Shacochis Edwards, a nurse in Maryland, discovered at the end of August that her daughter, Alden, had been exposed to the virus while masked at volleyball practice. Shacochis Edwards rapid-tested her family of four at home, while the high school ran a laboratory PCR on Alden. One week, 11 rapid antigen tests, 3 PCRs, and $125 later, their household was knee-deep in a baffling array of clashing results: Alden tested negative, then positive, then negative again, then positive again, then negative again; her father tested negative, then positive, then positive, then negative; Shacochis Edwards, who tested three times, and her son, who tested twice, stayed negative throughout. “None of it was clear,” she told me. Months after their testing saga, Shacochis Edwards is pretty sure the positives were wrong—but there’s simply no way to know for sure. Some conflicting results are just annoying. Others, though, can be a big problem when people misguidedly act on them—unknowingly sparking outbreaks, derailing treatment, and squandering time and resources. And the confusion doesn’t stop there. The tests come in an absurd number of flavors and packages, with subtle differences between brands. They’re deployed in a disorienting variety of settings: doctors’ offices, community testing sites, apartment living rooms, and more. They’re being asked to serve several very different purposes, including diagnosis of sick patients and screening of people who feel totally symptom-free. Our tests are imperfect—that’s not going to change. The trick, then, is learning to deal with their limitations; to rely on them, but also not ask too much. Tests can tell us only whether they found bits of the virus, at a single point in time.Tests are virus hunters. The best ones are able to accomplish two things: accurately pinpointing the pathogen in a person who’s definitely infected—a metric called sensitivity—and ruling out its existence in someone who’s definitely not, or specificity. Tests with great sensitivity will almost never mistake an infected person for a virus-free one—a false negative. High specificity, meanwhile, means reliably skirting false positives. Our tests accomplish this in two broad ways. They search for specific snippets of the virus’s genetic material, putting them in the category of molecular tests, or find hunks of pathogen protein, which is the job of antigen tests. (Most of the rapid tests you can find in stores are antigen, while PCR tests are molecular.) Both types will make mistakes, but whereas molecular tests repeatedly copy viral genetic material until it’s detectable, making it easier to root out the pathogen when it’s quite scarce, antigen tests just survey samples for SARS-CoV-2 proteins that are already there. That means they’re likelier to miss infections, especially in people with no symptoms. Even super-sensitive, super-specific tests can spit out more errors when they’re mishandled, or when people swab themselves sloppily. That can be pretty easy to do when instructions differ so much among brands, as they do for rapid antigen tests. (Wait 24 hours between tests! No, 36! Swivel it in your nose four times! No, five! Dip a strip in liquid! No, drop the liquid into a plastic strip! Wait 10 minutes for your result! No, 15!) [Read: The wrong way to test yourself for the coronavirus.] Random substances can also dupe certain tests: Soda, fruit juice, ketchup, and a bunch of other household liquids have produced rapid-antigen false positives, an oopsie that some kids in the United Kingdom have apparently been gleefully exploiting to recuse themselves from school. Manufacturing snafus can also trigger false positives, as recently happened with Ellume, a company that sells rapid molecular tests and had to recall some 2 million of them in the United States. (Sean Parsons, Ellume’s CEO, told me that the issue is now under control and that his company is “already producing and shipping new product to the U.S.”) Even when they’re perfectly deployed, tests can detect bits of the virus only at the moment a sample is taken. Testing “negative” for the virus isn’t some sort of permanent identity; it doesn’t even guarantee that the pathogen isn’t there. Viruses are always multiplying, and a test that can’t find the virus in someone’s nose in the morning might pick it up come afternoon. People can also contract the virus between the tests they take, making a negative, then a positive, another totally plausible scenario. That means a test that’s taken two days before a Thanksgiving gathering won’t have any bearing on a person’s status during the event itself. “People want tests to be prospective,” Gigi Kwik Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, told me. “None are.” Tests can serve a ton of different purposes.Recently, I asked more than two dozen people—co-workers, family members, experts, strangers on Twitter—what they envisioned the “perfect” coronavirus test to be. The answers I got were all over the place. People wanted tests that were cheap and accessible (which they’re currently not), ideally something that could give them a lightning-fast answer at home. They also, unsurprisingly, wanted totally accurate results. But what they wanted those results to accomplish differed immensely. Some said they’d test only if they were feeling unwell, while others were way more interested in using the tests as routine checks in the absence of symptoms or exposures, a tactic called screening, to reassure them that they weren’t infectious to others. [Read:]Massachusetts actually might have a way to keep schools open At least for now, certain tests will be better suited to some situations than others. “The best test to use depends on the question you’re asking of it,” Coffey told me. When someone’s sick or getting admitted into a hospital, for instance, health-care workers will generally reach first for the most precise, sensitive test they can get their hands on. A missed infection here is high-stakes: Someone could be excluded from a sorely needed treatment, or put other people at risk. But lab tests are inconvenient for the people who take them, and very often slow. Samples have to be collected by a professional, then sent out for processing; people can be left waiting for several days, during which their infection status might have changed. Using a rapid test can be much more convenient, especially if people feel unwell at home—and these tests do work great for that. But things get hairier when these products are used for screening purposes. Asymptomatic infections are a lot harder to detect in general, because there’s no obvious bodily signal to prompt a test. “You’re essentially randomly sampling,” which means more errors will inevitably crop up, Linoj Samuel, a clinical microbiologist at the Henry Ford Health System in Michigan, told me. To patch this problem, the FDA has green-lit several rapid tests that tell users to administer them serially—at least once every couple of days. A test that misses the virus one day will hopefully catch it the next, especially if levels are rising. But for those hoping to narrow in on the people who are carrying the most virus in their airway—and probably pose the biggest contagious risk to others—rapid antigen tests might be enough to do the trick precisely because they are less sensitive. They won’t catch all infections, but not all infections are infectious; a positive antigen result, at least, could be a decent indication that someone should stay home, even if they’re feeling perfectly fine. That logic isn’t airtight, though. Antigen-positive is not precisely synonymous with infectious; antigen negatives cannot guarantee that someone is not. “For SARS-CoV-2, we don’t know the threshold—how much virus you need to be carrying” to be contagious, Melissa B. Miller, a clinical microbiologist at the University of North Carolina at Chapel Hill, told me. People on the border of positivity, for instance, might still transmit. Many tests weren’t designed for one of the most basic ways we are using them.People are turning to testing for asymptomatic check-ins that can give them peace of mind before a big event, or even give them the go-ahead to travel overseas. But a lot of these screening tests were initially designed to diagnose people who were already sick—and the tests’ performance won’t necessarily hold when they’re being repeatedly used on symptom-free people at home. Part of the problem can be traced back to how the United States’ thinking on testing has evolved. Early on in the pandemic, regulatory agencies like the FDA prioritized tests for symptomatic patients; the agency has since noticeably shifted its stance, authorizing dozens of tests that can now be taken at home. But there are still some relics that have influenced how the tests have, and have not, been evaluated for use. Tests such as the Abbott BinaxNOW, for example, were first studied as a rapid diagnostic that people could take shortly after their symptoms first appeared. It can now be used as a screener, when it is serially administered at home to asymptomatic people (which is why the tests are sold in packs of two). But to nab that expanded authorization from the FDA, the company didn’t have to submit any data on the test’s performance when it was serially administered at home, or how well it worked in asymptomatic people. Instead, the FDA has been green-lighting serial tests based on how well their results match up to PCR results in symptomatic people. They just have to detect 80 percent of the infections that the super-sensitive molecular tests do, in a clinical setting. [Read: The one Thanksgiving necessity America forgot to stock.] I asked the FDA why that was. “The FDA does not feel that requiring specific serial-testing data from each manufacturer is necessary due to the current state of knowledge on serial testing,” James McKinney, a spokesperson, told me. (Some companies that already have products for sale, including Abbott and Becton, Dickinson, are collecting additional data now under FDA advisement.) The repurposing of tests feels a little weird, experts told me. “I don’t see how you can reuse the same data, for very different goals,” Jorge Caballero, a co-founder of Coders Against COVID, who’s been tracking coronavirus-test availability and performance, told me. That doesn’t mean these tests are useless if you don’t have symptoms. But without more evidence, we’re still determining exactly what they’re able to tell us when we self-administer them once, twice, or more, even as we’re feeling fine. Test results can tell us only so much.The results produced by a coronavirus test aren’t actually the end of the testing pipeline. Next comes interpretation, and that’s a nest of confusions in its own right. Sure, tests can be wrong, but the likelihood that they are wrong changes depending on who’s using them, how, and when. People don’t always talk about what to do when they’re shocked by a result—but that sense of surprise can sometimes be the first sign that the test’s intel is wrong. “People should have some confidence on how likely it is they have the disease when they test,” Coffey told me. “Ideally, the test should confirm what you already think.” Consider, for example, an unvaccinated person who starts feeling sniffly and feverish five days after mingling unmasked with a bunch of people at a party, several of whom tested positive the next day. That person’s likelihood of having the virus is pretty high; if they test positive, they can be pretty sure that’s right. Random screenings of healthy, vaccinated people with no symptoms and no known exposures, meanwhile, are way more likely to be negative, and positives here should raise at least a few more eyebrows. Some will be correct, but truly weird results may warrant a re-check with a more sensitive test. Yet another wrinkle has become particularly relevant as more and more people get vaccinated. Tests, which look only for pieces of pathogens, can’t distinguish between actively replicating virus that poses an actual transmission threat, and harmless hunks of virus left behind by immune cells that have obliterated the threat. A positive test for a vaccinated person might not mean exactly the same thing it does in someone who hasn’t yet had a shot—maybe, positive for positive, they’re less contagious. That’s not to say that noninfectious infections aren’t still important to track. But positives and negatives always have to be framed in context: when and why they’re being taken, and also by whom. Tests will have to be part of our future, for as long as this virus is with us. But understanding their drawbacks is just as essential as celebrating their perks. Unlike masks and vaccines, which can proactively stop sickness, tests are by default reactive, catching only infections that have already begun. In and of themselves, they “don’t stop transmission,” Coffey told me. “It’s about what you do with the test. If you don’t do anything with the result, the test did nothing.” from https://ift.tt/3nLTqiY Check out http://natthash.tumblr.com In 1993, a SWAT team equipped with night-vision goggles and assault rifles surrounded Mel Gibson’s mansion under the cover of darkness. They burst into the home, eventually finding the movie star wearing a bathrobe in his kitchen. Gibson put his hands up and the agents cuffed him immediately, over protestations that he had done nothing wrong, and certainly nothing dangerous. His crime? The possession of vitamin C tablets. “You know, like in oranges,” Gibson reminded the agents—and the viewers. This was a television commercial. In a dead-serious voice-over, the ad, which was backed by the dietary-supplement industry’s advocacy arm, claims that the federal government wants to classify your humble multivitamin capsules as drugs, a word loaded enough in the early ’90s to evoke crack instead of ibuprofen. The ad ends with a stark warning on a black screen: Viewers should contact the United States Senate to protect their freedoms. If they didn’t, their home could be raided next. The campaign was a huge success, according to Catherine Price, the author of Vitamania: How Vitamins Revolutionized the Way We Think About Food. At the time, the government was considering a bill to loosen the FDA’s regulatory reins on supplements, ensuring, among other things, that their makers would never have to prove their products’ safety or efficacy before marketing them to the public. People really did contact their senators en masse, Price told me, and the bill passed easily. The change rewrote the future entirely for the makers of dietary supplements—a category of products commonly referred to as vitamins but that also includes minerals, herbs, amino acids, and other “dietary substances.” From 1994 to 2016, the number of products on the American supplement market grew from about 4,000 to about 80,000; by one estimate, the market was worth more than $43 billion in 2019. As people have looked for ways to fortify their immune system during the coronavirus pandemic, the industry has grown even faster. When you walk down the vitamin aisle at Walmart or type your symptoms into Google, you’re now met with the infinite constellation of marketing opportunities this law created. This is true no matter what ailment you’re trying to address or corporeal obstacle you’re trying to overcome. Synthetic vitamins are combined with one another and with a slew of other substances in seemingly limitless permutations, sold by familiar consumer brands or movie stars or venture-backed start-ups in many different dosages and formats. There are now dietary-supplement blends advertised for focus, for combatting fatigue, for hair growth, for weight loss, for sexual potency, for surviving a hangover. The variety is overwhelming, as are the promises in all of those little capsules. But if you’re confused, don’t be: There’s a pretty good chance that whatever is lurking underneath all that promise is pretty similar to your average multivitamin. For the average person, vitamin is a slippery term. It denotes an invisible thing hiding in your food, a type of aisle at the drugstore, a product hawked by bland women on Instagram and angry men on YouTube. Multivitamin is similarly slippery, and more a term of art than a term of science. On an etymological level, it refers to any supplement that contains more than one vitamin. But according to Carol Haggans, a dietician and consultant at the National Institute of Health’s Office of Dietary Supplements, there is no regulatory standard for what multivitamin means, for what one must contain, or for what should be labeled as such. What the buying public tends to think of as a multivitamin usually contains all or part of a person’s recommended daily intake of actual vitamins (researchers have identified 13 essential to human health, and they’re the familiar ones: C, D, all the Bs), in addition to a number of minerals (iron, zinc, magnesium), and sometimes other non-vitamin substances such as ginger and ginkgo. Then there are the other multivitamins—the pills that make all the promises. These products, which claim to naturally “support” (we’ll talk about this word later) an even skin tone or jump-start productivity or calm nerves, almost always seem separate from the Centrum Silver that Grandad takes or the Flintstones chewable that appeared next to your childhood cereal bowl every morning; rarely will you find the word multivitamin on their labels or in their product descriptions online. But at a nutritional level, it’s often hard to see where these sorts of products are distinct. The luxury wellness company Moon Juice markets a hair-growth supplement that includes all 13 essential vitamins in doses similar to or exceeding those of common multivitamins, as well as minerals that are almost always present in such vitamins: iron, iodine, zinc. (Moon Juice did not respond to a request for comment.) H-Proof, a supplement that claims to proactively ameliorate the effects of hangovers, contains significant levels of nine vitamins, plus zinc and potassium. (Rachel Kaplan, H-Proof’s co-founder, told me that the company’s supplement is patented and therefore distinct from others on the market. She said the supplement is safe to take with multivitamins.) The list goes on and on: Boost your immune system! Support your digestive health! Increase productivity! Even dietary products like 5-Hour Energy shots have a significant ingredient overlap with multivitamins—although, presumably, your multi doesn’t also include more than 200mg of caffeine. [Read: The year America’s hair fell out] Other companies take a different path to a similar destination, with vast product lineups that are positioned as complementary and customizable—an alternative to one-size-fits-all traditional health care. Hum Nutrition, whose products are sold at Sephora and Bloomingdale’s, offers a cover-your-bases multivitamin as well as a broad assortment of products that shoppers can use to build their own personal health routines. These ancillary products have names like Uber Energy and Hair Sweet Hair, and many of them include blends of vitamins and minerals already found in the company’s multivitamin, sometimes with other herbs or extracts mixed in. Other add-ons are just standard-issue vitamin D or biotin supplements, rebranded as Here Comes the Sun or Killer Nails. Care/of, a line of dietary supplements available at Target, offers a smaller but structurally similar setup, with a standard multi for men or women and add-ons for focus or energy or immunity. You can buy a multivitamin, and then build your own multivitamin, perhaps unwittingly, to take on top of it. Graham Rigby, Care/of’s chief innovation officer, told me via email that the brand’s mix-and-match line is formulated to fall below any known safety limits for its ingredients. Shauna Aminzadeh, a spokesperson for Hum Nutrition, told me that the company’s build-your-own vitamin regimen is “targeted to very specific health and beauty concerns” and that “key ingredients are backed by clinical trials.” Cross-referencing products’ ingredients against one another is an exhaustingly detailed process. The print is tiny, the numbers are very close together, and different manufacturers list the same ingredients in different orders and under different names. If you’re shopping online, some websites won’t let you zoom in far enough to easily read the ingredient lists. Nothing about how supplements are marketed or packaged makes them easy to understand or compare for the people buying them. The regulatory changes passed in 1994 mean manufacturers are not required to disclose much at all, including potential side effects and drug interactions. If they claim clinical proof of their products’ efficacy, they are not required to make that proof available for scrutiny, or even to demonstrate that it exists. This system is how you end up with people stacking supplements on top of one another with no real understanding of what’s in them, and no real understanding of what to expect. According to Tod Cooperman, the founder and president of ConsumerLab.com, which conducts independent lab testing on retail dietary supplements, the end experience for buyers often looks similar, even if they select different products from different brands: They are taking at least one multivitamin, and maybe the equivalent of several. “What you typically see is that marketers are formulating products based on the smallest scraps of evidence for an ingredient that might relate to a condition,” he told me. “There’s the expectation that the products are going to contain many ingredients if there’s some magic to the formula, and obviously, that is what [the marketers] are shooting for.” Because consuming a minimum amount of certain vitamins and minerals is essential to human life, there are studies linking all of them to a slew of bodily processes. That means supplement marketers can advertise their products as supporting or encouraging (importantly, not causing) healthy immune function or clear skin or good mood, even if there’s no proof that taking large amounts of these substances leads to any additional effect. Vitamin C, for example, is indeed important for your immune system, and it figures prominently in many of the immunity-boosting supplements that have become especially popular during the pandemic. But as with all vitamins and essential minerals, infinite Vitamin C is not infinitely beneficial. Consuming it is helpful only to a point that most people hit through their diets, Haggan, the NIH dietician, told me. That point is far lower than the megadoses included in many immunity supplements. Where supplements make a real difference is in people with genuine nutritional deficiencies or with specific health conditions, Haggan said. For example, pregnant people need to get more folic acid than the average person in order to prevent some birth defects, and vegans often don’t get enough B12. People with enough money to build bespoke personal supplement regimens rarely have deficiencies. Most Americans, for that matter, get everything they need by eating and going outside. Beyond the known essential nutrients, we have even less understanding of what—if anything—other supplement ingredients do, and in what amounts they might do it. Small studies abound, many of them conducted on rodents instead of humans. Although this type of research is crucial to scientists, Haggan said, it in no way proves that a particular effect can be extrapolated to humans through use of any particular consumer product. This is the part where discussion of supplements gets tricky. Most dietary supplements are unlikely to hurt an otherwise healthy person in the short term, Haggan said, even if they contain megadoses of certain ingredients. In a country where the health-care system is so often inaccessible and unreliable, isn’t it good that lots of people want to do what’s in their power to shore up their personal health outside of that system? Isn’t it good that vital nutrients are widely available and pretty affordable? Who cares if some people treat vitamins like edible astrology? Americans, as Mel Gibson told us all those years ago, want the opportunity to decide for themselves what goes in their bodies. The problem is that the supplement industry, as it stands currently, ensures that making good personal choices with its products is almost impossible. Because even the most basic proof of a product’s efficacy and safety isn’t required in order to start selling, that research isn’t done. Cooperman told me that about one in five of the supplements that ConsumerLab tests is substantially different than what it claims to be. The ingredient levels are much too low or much too high. The pills don’t break apart to allow their ingredients to be absorbed by the body. The oil-based capsules go rancid. Some supplements are tainted with pesticides, metals, or actual pharmaceuticals. Price recounted an anecdote she heard from a chemist during her Vitamania reporting: While evaluating a male-enhancement supplement that was supposed to contain a traditional mix of Chinese herbs, the chemist cracked open a capsule and a chunk of a blue Viagra tablet fell out. (In the male-enhancement world, this kind of thing is more common than you might expect.) Supplements can be dangerous. If you pile a few different types on top of one another, and then pile those on top of the vitamins and minerals you’re already getting from food—itself commonly fortified or enriched with extra vitamins in the United States—you could very well be megadosing lots of different substances without realizing it. In the short term, with most supplement ingredients, that’s probably fine—they are water-soluble, which means you’ll excrete the excess in urine. But for fat-soluble vitamins such as A, D, and E, as well as minerals such as calcium and iron, according to Price, the overage can accumulate in bodily tissues over time. That helps make multivitamins an overdose risk and can cause serious problems—hair loss, fainting, cardiac issues, seizures, coma, and even death. One recent survey found that one in eight people said either they or a member of their immediate family had experienced a severe side effect after taking a dietary supplement. These conditions attract bad actors. Multilevel marketing schemes, conspiracy theorists, and celebrities looking to diversify their revenue streams are all serious players in the American supplement market, many of them hawking products that are extraordinarily similar to one another, just with different packaging and a different pitch. Caveat emptor doesn’t seem to cut it, but maybe this will: Whatever it is that sounds so promising might just be a multivitamin, and when was the last time one of those changed your life? from https://ift.tt/3xlrllG Check out http://natthash.tumblr.com The first part of what may be the first epidemiologic text ever written begins like so: “Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year.” The book is On Airs, Waters, and Places, written by Hippocrates around 400 B.C. Two and a half millennia later, the Northern Hemisphere is staring down its coming season of the year with growing apprehension. America’s grimmest phase of the coronavirus pandemic so far occurred from November 2020 to February 2021. Now the calendar has turned to a new November, and even though the majority of Americans are fully vaccinated against COVID-19, cases are once again, horrifyingly, on the rise. If Hippocrates was right, we could be doomed to repeat the sickness and death that defined last winter. To be fair, Hippocrates also thought that among the most important factors in anyone’s health was their balance of black and yellow bile. But evidence is piling up that COVID really is a seasonal disease, surging with the weather and the annual rhythms of human life. If that’s the case, then understanding those seasonal patterns could help us predict where the virus is headed next, and address its attacks in advance. [Read: The pandemic’s next turn hinges on three unknowns] The seasonal-COVID hypothesis, and its promised benefits for pandemic planning, have been around nearly as long as the disease itself. Way back in February 2020, President Donald Trump predicted that in April, “when it gets a little warmer,” the coronavirus would “miraculously” disappear. That clearly didn’t happen, but evidence of seasonality, the thinking went, might show up in summer, when things got really warm. In fact, by mid-July, the country saw its highest case rates yet—and then the massive winter surge easily surpassed it. The virus came in waves, but the waves were hitting all year round. COVID’s seasonality hadn’t been disproved; to know for sure, we’d need to wait and see what happened next. Now we have nearly two years’ worth of data—from eight full seasons of pandemic—to pick apart for clues, and may well be closing in on an answer. We also know something we didn’t in spring 2020: In all likelihood, we will not eradicate COVID. That makes it all the more important that we know how cases might ebb and flow with weather in the months and years to come. Anyone who lives in a temperate climate has an intuitive understanding of seasonal disease. The most canonical example is the common cold—just look at what it’s named. But infecting more people in cold weather is far from the only once-a-year cycle a disease can settle into. Lyme disease peaks in the summer. Polio was historically a summer sickness. Even genital herpes tends to spike around the spring and summer in the United States. The same disease can also show different patterns in different places. Americans are used to a winter flu season, but in Bangladesh, flu cases spike during the monsoon season, which runs from May to September and is the warmest part of the year. As one public-health researcher argued in a 2018 paper, seasonal cycles “may be a ubiquitous feature of human infectious diseases.” [Read: We accidentally solved the flu. Now what?] Some seasonal disease patterns are a result of how efficiently a particular pathogen invades our bodies in particular weather. Flu, for example, is much better at surviving and traveling between humans in dry air. Early in the pandemic, a group of researchers led by Tamma Carleton, an environmental economist now at UC Santa Barbara, checked to see how COVID fared in different weather conditions around the world. Their study didn’t find much of a role for temperature or humidity, but suggested that case rates would go up in a particular area during periods of lower UV exposure. Since then, the coronavirus has been shown to die off in the presence of UV rays with the same wavelength as sunlight. (That, in combination with airflow, could help explain why the virus tends to spread much less outdoors.) But Carleton’s study also showed that the influence of sunlight was minimal in comparison with that of shifting human behavior. “How we interact with each other, where we interact with each other, changes so much with different climate conditions,” she told me. She suspects that her study picked up on both the direct virucidal effects of sunlight and the fact that people might be more inclined to gather inside when it’s crummy out. Both would contribute to the seasonality of COVID, she said, but, “I’m not sure I’m that hopeful in ever disentangling them.” [Read: The plan to stop every respiratory virus at once] As Carleton and her colleagues did their work in the spring of 2020, they could look only at case rates over periods of weeks. Subsequent research would have access to many months’ worth of data. In July 2021, a team from the University of Pittsburgh put out a study (which has not yet been peer-reviewed) showing that differentiating between regions in North America reveals a much stronger seasonal pattern. “You don’t get a clear signal just from analyzing the United States as a whole,” Hawre Jalal, one of the authors of that study, told me. That could be because warmth doesn’t mean the same thing for all Americans. Those who live in cooler parts of the country can spend time outside more easily in July than January, while the opposite is true for residents of the hottest parts of the South. (No one has yet empirically proved a link between air-conditioning weather and indoor transmission of the virus.) By sifting for seasonal patterns across individual states, Jalal and his collaborators found very robust results. They argue that the calendar of COVID in North America has already taken shape, in the form of three repeating waves like the ones that swept the continent in 2020: one starting in New England and eastern Canada in the spring, the second traveling north from Mexico over the summer, and the third emanating in all directions from the Dakotas during the fall. In keeping with that idea, their paper predicted a summer 2021 wave in the South, and a fall 2021 wave in the north-central states—which is more or less exactly what happened. This three-peaked seasonality, if it’s real, would seem to make COVID an outlier, at least compared with single-season diseases like the flu. But if COVID really is driven more by seasonal changes than factors such as masking and vaccination rates, no community should expect to see a surge more than once a year. The disease would still behave like the flu on a local level, in the sense that each place would see one peak season every year—even while the country overall had three. This pattern may sharpen in the next few years. David Fisman, an epidemiologist at the University of Toronto, told me that the patterning of past pandemics has tended to follow a sort of script: chaos, then seasonality, then less-destructive chaos. When a pandemic first arrives, virtually everyone on Earth is vulnerable, so the pathogen rips through populations like wildfire. Then, as more people develop immunity through vaccination or infection, the fire needs more help to find new fuel, and seasonal influences become more apparent. Finally, once the overwhelming majority of the population is immune, those same influences could become so subdued as to be invisible. For a lot of diseases, Fisman said, the effective reproduction number—that is, the number of people to whom each infected person passes a disease, on average—hovers below one during the off-season. Then, the kids go back to school, or the deer-tick nymphs emerge into the world, or the humidity drops, and the disease suddenly has the upper hand. The reproduction number jumps above one for a few months, before dropping again. Transmissibility was elevated during the early months of the pandemic, and again during the Delta-variant wave, which could have pushed the country back toward the initial-chaos phase and blunted any seasonal influence on COVID. Maybe in the absence of Delta, we’d have realized that transmission is even more seasonal than it looks right now. [Scott Gottlieb: A second major seasonal virus won’t leave us any choice] At this point, even initial skeptics agree that COVID rates are varying with the seasons. Ben Zaitchik, an Earth scientist at Johns Hopkins University who co-chairs the World Meteorological Organization’s COVID-19 Research Task Team, once found seasonality claims to be weak. In February, he co-wrote a review of 43 studies of the topic (including Carleton’s) from early in the pandemic. Researchers simply didn’t have enough data in the first several months of 2020 to find strong patterns, he told me. Testing was inconsistent. Many teams, unable to compare the cold and warm or rainy and dry seasons in particular places, compared one region’s cold with another’s heat—say, winter in Italy with summer in Australia—which doesn’t tell you much about what will happen once Italy gets hot and Australia gets cold. But the data have since improved enough that Zaitchik feels confident saying that weather influences COVID transmission in a statistically significant way. He’s not as convinced that this influence matters for public health. “COVID-19 has proven beyond a doubt that it can create hugely deadly outbreaks anywhere in the world at any time of the year. And that’s still true,” Zaitchik said. Until we see the end of countercyclical outbreaks—until Montana stops having August surges, and Florida’s cases stay flat in February—arguing that seasonality is a dominant driver of the disease will be difficult. And if it isn’t yet the dominant pattern, staking a public-health response on it could backfire. “I think that a lot of responsible people in the decision-making space kind of say, ‘I don’t want to talk about seasonality now, because I’m not ready to, because I know that there are bigger risk factors to be taken into account,’” Zaitchik said. Telling northerners they can let their guard down in the summer, and southerners they can party like it’s 2019 over the winter, could have disastrous consequences. [Read: Six rules that will define our second pandemic winter] At the same time, avoiding all discussion of seasonality could mean missing opportunities to fight COVID smarter, not harder. Donald Burke, one of Jalal’s co-authors, suggested that public-health officials could plan to deploy extra anti-COVID strategies in times when and places where the virus is at a disadvantage, given that beating back a disease is much easier when it’s not circulating widely. Jalal said that the United States could direct resources such as health-care workers and PPE to areas that are likely to see a wave before it arrives, rather than reacting to it once it’s already half-crashed. If these sorts of ideas haven’t gotten much traction, Jalal said, it may be because some researchers are underestimating the importance of seasonality. He warns against concentrating too much on the global or national picture, where the many waves in several seasons make the pattern less obvious. Burke suggested that wishful thinking could also be to blame: “I think most people want to believe that we have more power over the course of the epidemic,” he said. To acknowledge a strong seasonal influence might feel like admitting defeat: If Louisiana is going to face devastating case rates every summer, and Minnesota will fall prey to a winter surge like clockwork, how much can we really do? But a regular pattern doesn’t have to mean inevitable suffering. Pandemic-fighting policies can take strategic account of seasonality; they’ve done so before. “Having made these investigations, and knowing beforehand the seasons,” Hippocrates wrote, a doctor “must be acquainted with each particular, and must succeed in the preservation of health, and be by no means unsuccessful in the practice of his art.” from https://ift.tt/30HkAPg Check out http://natthash.tumblr.com Winter has a way of bringing out the worst of the coronavirus. Last year, the season saw a record surge that left nearly 250,000 Americans dead and hospitals overwhelmed around the country. This year, we are much better prepared, with effective vaccines--and, soon, powerful antivirals—that defang the coronavirus, but cases seem to be on the rise again, prompting fears of another big surge. How bad will it get? We are no longer in the most dangerous phase of the pandemic, but we also have not reached the end. So COVID-19’s trajectory over the next few months will depend on three key unknowns: how our immunity holds up, how the virus changes, and how we behave. These unknowns may also play out differently state to state, town to town, but together they will determine what ends up happening this winter. How Much Immunity Do We Even Have?Here are the basic numbers: The U.S. has fully vaccinated 59 percent of the country and recorded enough cases to account for 14 percent of the population. (Though, given limited testing, those case numbers almost certainly underestimate true infections.) What we don’t know is how to put these two numbers together, says Elizabeth Halloran, an epidemiologist at the Fred Hutchinson Cancer Research Center. What percentage of Americans have immunity against the coronavirus—from vaccines or infection or both? This is the key number that will determine the strength of our immunity wall this winter, but it’s impossible to pin down with the data we have. This uncertainty matters because even a small percentage difference in overall immunity translates to a large number of susceptible people. For example, an additional 5 percent of Americans without immunity is 16.5 million people, and 16.5 million additional infections could mean hundreds of thousands more hospitalizations. Because unvaccinated people tend to cluster geographically and because many hospital intensive-care units run close to capacity even in non-pandemic times, it doesn’t take very many sick patients to overwhelm a local health-care system. What’s happening in Europe, says Ali Ellebedy, an immunologist at Washington University in St. Louis, is also a “red sign.” Several countries in Western Europe, which are more highly vaccinated than the U.S., are already seeing spikes heading into winter. Cases in Germany, which has vaccinated nearly 70 percent of its population, have increased sharply, overwhelming hospitals and spurring renewed restrictions on the unvaccinated. The U.S. does have a bit more immunity from previous infections than Germany because it’s had bigger past COVID waves, but it still has plenty of susceptible people. The strength of immunity also varies from person to person. Immunity from past infection, in particular, can be quite variable. Vaccine-induced immunity tends to be more consistent, but older people and immunocompromised people mount weaker responses. And immunity against infection also clearly wanes over time in everyone, meaning breakthrough infections are becoming more common. Boosters, which are poised to be available to all adults soon, can counteract the waning this winter, though we don’t yet know how durable that protection will be in the long term. If the sum of all this immunity is on the higher side, this winter might be relatively gentle; if not, we could be in store for yet another taxing surge. Will New Variants Emerge?At the beginning of the pandemic, scientists thought that this coronavirus mutated fairly slowly. Then, in late 2020, a more transmissible Alpha variant came along. And then an even more transmissible Delta variant emerged. In a year, the virus more than doubled its contagiousness. The evolution of this coronavirus may now be slowing, but that doesn’t mean it’s stopped: We should expect the coronavirus to keep changing. Alpha and Delta were evolutionary winners because they are just so contagious, and the virus could possibly find ways to up its transmissibility even more. But as more people get vaccinated or infected, our collective immunity gives more and more of an edge to variants that can evade the immune system instead. Delta has some of this ability already. In the future, says Sarah Cobey, an evolutionary biologist at the University of Chicago, “I think most fitness improvements are going to come from immune escape.” The Beta and Gamma variants also eroded immune protection, but they weren’t able to compete with the current Delta variant. There may yet be new variants that can. Whether any of this will happen in time to make a difference this winter is impossible to know, but it will happen eventually. This is just how evolution works. Other coronaviruses that cause the common cold also change every year—as does the flu. The viruses are always causing reinfections, but each reinfection also refreshes the immune system’s memory. [Read: The coronavirus could get worse] A new variant could change the pandemic trajectory again this winter, but it’s not likely to reset the pandemic clock back to March 2020. We might end up with a variant that causes more breakthrough infections or reinfections, but our immune systems won’t be totally fooled. How Will People Spread the Virus?The coronavirus doesn’t hop on planes, drive across state lines, or attend holiday parties. We do. COVID-19 spreads when we spread it, and predicting what people will do has been one of the biggest challenges of modeling the pandemic. “We’re constantly surprised when things are messier and weirder,” says Jon Zelner, an epidemiologist at the University of Michigan. The Delta wave in the Deep South over the summer, for example, ebbed in the late summer and early fall even though many COVID restrictions didn’t come back. If anything, you might have expected cases to rise at that moment, because schools full of unmasked and unvaccinated children were reopening. So what happened? One possible explanation is that people became more careful with masking and social distancing as they saw cases rising around them. More people in the South did get vaccinated, though the rates still lag behind those in the highly vaccinated Northeast. Are surges “self-limiting because people are modifying their behavior in response to recent surges?” Cobey says. “That’s just a really open question.” Weather may also drive behavior; as temperatures cooled down in the South, people might have spent more time outdoors. Another possible factor in ending the summer surge is that the virus may have simply infected everyone it could find at the time—but that is not the same as saying it has infected everyone in those states. The coronavirus doesn’t spread evenly across a region, like ink through water. Instead, it has to travel along networks of connection between people. COVID-19 can run through an entire household or workplace, but it can’t jump to the next one unless people are moving in between them. By sheer chance, the coronavirus may find some pockets of susceptible people but not others in any given wave. “There’s a kind of randomness to it,” Zelner says. This winter, we should expect a local flare-up every time the virus finds a pocket of susceptibility. But it’s hard to predict exactly when and where that will happen. The country’s current COVID hot spots are Michigan, Minnesota, and New Mexico, three states with no obvious connection among them. [Read: America has lost the plot on COVID] By winter’s end, the U.S. will emerge with more immunity than it has now—either through infection or, much preferable, through vaccinating more people. “To me, this winter is the last stand,” Zelner says. However these three unknowns play out this winter, COVID will eventually begin to fade as a disruptive force in our lives as it becomes endemic. We’re not quite there yet, but our second pandemic winter will bring us one step closer. from https://ift.tt/327ykCZ Check out http://natthash.tumblr.com In late February 2020, only a couple of weeks after the pandemic coronavirus disease had even received a formal name, a man with a terrible cough and fever showed up at one of the ProHealth Urgent Care centers in Queens, New York. At that point, no COVID-19 cases had yet been confirmed in New York City, but numbers were on the rise in spots across the country, and the man had recently been at a conference. An ER-trained physician donned protective goggles, a face mask, and gloves, and went in to swab the man’s nose with a giant Q-tip. With any luck at all, this would show he’d gotten sick from some other, more mundane pathogen—and that the timing of his symptoms was just a grim coincidence. Within a few minutes, the staffers got just the answer they were hoping for: The swab was positive for influenza. But Daniel Griffin, a researcher at Columbia University and the chief of the infectious-disease division at ProHealth, wasn’t ready to let down his guard. “Wait a second,” he says he told the health-care team, as colleagues prepared to shed their protective gear. “How do we know this gentleman isn’t also infected with the pandemic virus?” He suggested that they all assume the worst until they’d had a chance to run some further tests. In early March, those results finally came in: Yes, the man was positive for the pandemic virus. His wife was, too, and so were their two kids. The whole family had COVID-19 and the flu. By late summer 2020, many experts were warning of a potential “twindemic” of these two diseases. But their fears were as much about the possibility that COVID-19 and influenza would combine to overwhelm health systems as the possibility that they would combine to overwhelm an individual’s immune system. In 2021, we still don’t know much about how—or how often—the flu virus and SARS-CoV-2 act in tandem within the same body. A very early study from China in January 2020 found zero cases of coinfection of these two pathogens among 99 COVID-19 patients, but a follow-up, conducted a month later at a COVID-19 hospital, concluded that about one in eight had both diseases at the same time. Whatever the historic prevalence of coinfection, the twindemic never happened last winter. Perhaps due to mask wearing and social distancing, flu numbers in the U.S. were much, much lower than normal during the 2020–21 season. But with pandemic restrictions relaxing, and fewer people getting flu shots, the same warnings have returned. “I actually think it’s more of a risk this year,” Griffin told me. Cases like the ones he saw almost two years ago could become far more common. In fact, new research suggests that getting coinfections—not just of COVID-19 and flu, but of many one-two punches of pathogens—may be far more common than we thought. Doctors’ understanding of what these coinfections mean for care and treatment remains preliminary, but they could well have important consequences. Some colds feel worse than others. On occasion they can be a terrible ordeal, knocking us out for days, leaving us miserable; other times they are barely a bother at all. This isn’t a great mystery or anything: We know that some cold viruses are nastier than others, and that we can be exposed to larger or smaller amounts of the same virus; we also know that our immune systems can be stronger or weaker at any given time. But what if another, unacknowledged factor is at play? What if the nastiest case of sniffles you ever had was, in fact, two viruses infecting your body at the same time—a double-whammy cold? Within the past decade, new molecular diagnostics have made such coinfections much easier to identify—and they’ve turned up some disquieting statistics. Recent screening studies have found that 14 to 70 percent of those hospitalized with flu-like illness test positive for more than one viral pathogen. [Read: We accidentally solved the flu. Now what?] For COVID-19, the acquisition of multiple infections appears to be associated with bad outcomes. People with severe COVID-19 who ended up in the ICU for many days and sometimes weeks were prone to developing additional illnesses—what’s known as “superinfection”—while in the hospital. It’s hard to shake the images of COVID-19 patients disfigured by mucormycosis, also known as black fungus; but those who end up in the ICU are also susceptible to ventilator-associated pneumonias and sepsis. People sick with flu are similarly prone to bacterial superinfections, which are thought to have caused many of the deaths during the 1918 pandemic, according to Brianne Barker, a professor at Drew University, in New Jersey, who teaches virology and immunology. Some researchers have estimated that, all told, as many as half of all COVID-19 deaths can be attributed to mixed infections, although others put the number considerably lower. According to an analysis from last spring of more than 100 studies, people who tested positive for both SARS-CoV-2 and a second pathogen had triple the odds of dying compared with those who had only COVID-19. That added risk wasn’t just associated with superinfections that came on during a patient’s hospital stay; according to this analysis, it applied just as well to those who had coinfections from the time they were first diagnosed with COVID-19. Those data come from studies of acute coinfections such as COVID-19 and flu—diseases that the body typically clears in a matter of days or weeks. Our bodies also hold a soup of chronic coinfections that never really go away. These include a host of herpes viruses such as cytomegalovirus, a lifelong presence in 50 to 80 percent of U.S. adults; and the varicella-zoster virus, which causes chicken pox and shingles. Another one that sticks with us forever is the Epstein-Barr virus, which can cause mononucleosis (“mono”) when a person first is exposed and infects an estimated 90 percent of people worldwide. These lifelong infections, kept in check by our immune systems, are usually irrelevant to later encounters with a different pathogen. But in certain cases they might be reawakened by a new disease that temporarily weakens our immune defenses. For example, some small studies during the pandemic offered hints that severe COVID-19 is associated with a quickening of latent cytomegalovirus or herpes simplex virus. On the flip side, chronic infection with lifelong viruses can make people more vulnerable to acute infection. The classic example of this is HIV, which goes after the immune system itself and depletes the body’s T cells. Individuals with the virus are far more likely to get tuberculosis, and as a result tuberculosis is a leading cause of death in people living with HIV. Coinfections aren’t always bad news for the patient. In some cases, pathogens are pitted against one another, competing for the same host cells. Take human papillomavirus, which causes cervical cancer and genital warts. A 2018 laboratory study found that a single human skin or cervical cell could be infected simultaneously with two different strains of HPV—and that when this happened, one of the strains ended up less able to generate copies of itself that would go on to infect further cells. Researchers believe that in some situations a viral infection might also protect you by activating the body’s innate immune response, priming it to thwart a second infection that arrives later. In a third scenario, an initial infection might also spark the activation of T cells that happen to recognize a second, similar invading pathogen—an effect known as a “bystander response.” That’s what happens to people who are infected with both dengue virus and Zika virus, although whether this really offers protection (or whether it might even cause some harm) is unclear. Doctors have tried, on rare occasions, to induce coinfections as a treatment. A century ago, before antibiotic drugs were invented, the Austrian neuropsychiatrist Julius Wagner-Jauregg advocated for the use of malaria parasites as a cure for psychosis caused by syphilis. The treatment caused fever in patients, which Wagner-Jauregg found would ameliorate the psychosis. (Quinine would be administered to treat the malaria as soon as the disease had done its job.) Wagner-Jauregg won a Nobel Prize for this discovery, but his work would be overshadowed by his endorsement of eugenics and eventual support for the Nazis. Later scientists took up the idea of using other pathogens—in particular the common parasitic worm Ascaris lumbricoides--against malaria itself. It’s possible that even the dreaded collision of coronavirus and influenza might actually have some benefits for individuals. For a study published in 2018, a group of scientists in Moscow, Idaho, squirted a common-cold-type virus, either a rhinovirus or a mouse coronavirus, up the noses of white mice. When they followed these infections, two days later, with a squirt of a mouse-adapted flu virus, the mice fared better—they lived longer and showed fewer symptoms, such as ruffled fur and labored breathing—than other mice that were never given colds. The researchers suggested that the rhinovirus or coronavirus had set off an “early but controlled” inflammatory response in the animals’ lungs, which then helped them defeat the flu virus. For these mice, at least, a lab-induced one-two was protective. New testing techniques have revealed a combinatorial quagmire of infections in individual patients, even in routine practice. When doctors do a nose or throat swab on a sick child, the results sometimes indicate the presence of multiple pathogens, says Aubrey Cunnington, who is the head of the pediatric-infectious-diseases section at Imperial College London. The kids could turn out to have a mix of rhinovirus, parainfluenza, and respiratory syncytial virus. “We often see two or even three different viruses come up positive,” he told me. “Coexisting infections with different organisms, particularly viruses, are the rule rather than the exception.” But what, exactly, do these coinfections mean? The implications of smorgasbord results remain unclear. “We have rather limited understanding of how they interact with one another, with bacteria, and other pathogens, to result in the illness affecting each patient,” Cunnington said, adding that children with more than one pathogen don’t necessarily seem sicker than others. In other words, having a double-whammy cold may not be especially bad. The same could be true for certain pandemic coinfections: Some research suggests that many COVID-19 patients have bacteria, fungi, or other viruses in their systems at the time of diagnosis, but with perhaps little reason for concern. One study at a local Chinese hospital, for example, found that about 94 percent of COVID-19 patients tested positive for either acute or chronic coinfections, but that rate was even higher (96 percent) for those with mild or asymptomatic illness. Our immune systems can produce different antibodies simultaneously, so they can typically multitask against different pathogens. It’s sometimes hard to tell which of several microbes in a patient is the one causing illness. The new molecular tests are so sensitive, they may pick up on harmless genetic fragments that linger in the body after a pathogen has been cleared—identifying a “coinfection” that is no longer even active. Griffin suggested that multiple-pathogen screens should still be used for patients hospitalized with COVID-19, or with any other grave disease, so that treatment can be tailored to the underlying need. If someone has the flu in addition to COVID-19, for example, a doctor might offer Tamiflu, or antibiotics might be given for a hidden bacterial infection. But Griffin warned that when molecular testing implicates multiple culprits, those results should be validated with further lab tests, such as trying to grow the pathogens in the lab. “You still want to do the cultures,” Griffin told me. Looking for coinfections creates more work for doctors, and interpreting the results when they find multiple pathogens lurking inside someone’s organs makes for an even bigger clinical headache. But more and more studies are finding that coinfections are commonplace, so it’s important not to ignore them—particularly for patients who are very ill. Not everything in biology abides by Ockham’s razor, a principle attributed to the Franciscan friar and philosopher William of Ockham, which argues that, when given several possible solutions, the one with the least complexity is the most likely. “Ockham was not a physician,” Griffin said. “You can have more than one thing going on. from https://ift.tt/3kLal3f Check out http://natthash.tumblr.com The moment that broke Cassie Alexander came nine months into the pandemic. As an intensive-care-unit nurse of 14 years, Alexander had seen plenty of “Hellraiser stuff,” she told me. But when COVID-19 hit her Bay Area hospital, she witnessed “death on a scale I had never seen before.” Last December, at the height of the winter surge, she cared for a patient who had caught the coronavirus after being pressured into a Thanksgiving dinner. Their lungs were so ruined that only a hand-pumped ventilation bag could supply enough oxygen. Alexander squeezed the bag every two seconds for 40 minutes straight to give the family time to say goodbye. Her hands cramped and blistered as the family screamed and prayed. When one of them said that a miracle might happen, Alexander found herself thinking, I am the miracle. I’m the only person keeping your loved one alive. (Cassie Alexander is a pseudonym that she has used when writing a book about these experiences. I agreed to use that pseudonym here.) The senselessness of the death, and her guilt over her own resentment, messed her up. Weeks later, when the same family called to ask if the staff had really done everything they could, “it was like being punched in the gut,” she told me. She had given everything—to that patient, and to the stream of others who had died in the same room. She felt like a stranger to herself, a commodity to her hospital, and an outsider to her own relatives, who downplayed the pandemic despite everything she told them. In April, she texted her friends: “Nothing like feeling strongly suicidal at a job where you’re supposed to be keeping people alive.” Shortly after, she was diagnosed with post-traumatic stress disorder, and she left her job. Since COVID-19 first pummeled the U.S., Americans have been told to flatten the curve lest hospitals be overwhelmed. But hospitals have been overwhelmed. The nation has avoided the most apocalyptic scenarios, such as ventilators running out by the thousands, but it’s still sleepwalked into repeated surges that have overrun the capacity of many hospitals, killed more than 762,000 people, and traumatized countless health-care workers. “It’s like it takes a piece of you every time you walk in,” says Ashley Harlow, a Virginia-based nurse practitioner who left her ICU after watching her grandmother Nellie die there in December. She and others have gotten through the surges on adrenaline and camaraderie, only to realize, once the ICUs are empty, that so too are they. Some health-care workers have lost their jobs during the pandemic, while others have been forced to leave because they’ve contracted long COVID and can no longer work. But many choose to leave, including “people whom I thought would nurse patients until the day they died,” Amanda Bettencourt, the president-elect of the American Association of Critical-Care Nurses, told me. The U.S. Bureau of Labor Statistics estimates that the health-care sector has lost nearly half a million workers since February 2020. Morning Consult, a survey research company, says that 18 percent of health-care workers have quit since the pandemic began, while 12 percent have been laid off. Stories about these departures have been trickling out, but they might portend a bigger exodus. Morning Consult, in the same survey, found that 31 percent of the remaining health-care workers have considered leaving their employer, while the American Association of Critical-Care Nurses found that 66 percent of acute and critical-care nurses have thought about quitting nursing entirely. “We’ve never seen numbers like that before,” Bettencourt told me. Normally, she said, only 20 percent would even consider leaving their institution, let alone the entire profession. Esther Choo, an emergency physician at Oregon Health and Science University, told me that she now cringes when a colleague approaches her at the end of a shift, because she fears that they’ll quietly announce their resignation too. Vineet Arora, who is dean for medical education at University of Chicago Medicine, says that “in meetings with other health-care leaders, when we go around the room, everyone says, ‘We’re struggling to retain our workforce.’ Nobody says, ‘We’re fine.’” When national COVID hospitalizations fell in September and October, it was possible to hope that the health-care system had already endured the worst of the pandemic. But that decline is now starting to plateau, and in 17 states hospitalizations are rising. And even if the country dodges another surge over the winter, the health-care system is hemorrhaging from the untreated wounds of the past two years. “In my experience, physicians are some of the most resilient people out there,” Sheetal Rao, a primary-care physician who left her job last October, told me. “When this group of people starts leaving en masse, something is very wrong.” Health-care workers, under any circumstances, live in the thick of death, stress, and trauma. “You go in knowing those are the things you’ll see,” Cassandra Werry, an ICU nurse currently working in Idaho, told me. “Not everyone pulls through, but at the end of the day, the point is to get people better. You strive for those wins.” COVID-19 has upset that balance, confronting even experienced people with the worst conditions they have ever faced and turning difficult jobs into unbearable ones. In the spring of 2020, “I’d walk past an ice truck of dead bodies, and pictures on the wall of cleaning staff and nurses who’d died, into a room with more dead bodies,” Lindsay Fox, a former emergency-medicine doctor from Newark, New Jersey, told me. At the same time, Artec Durham, an ICU nurse from Flagstaff, Arizona, was watching his hospital fill with patients from the Navajo Nation. “Nearly every one of them died, and there was nothing we could do,” he said. “We ran out of body bags.” Most drugs for COVID-19 are either useless, incrementally beneficial, or—as with the new, promising antivirals—mostly effective in the disease’s early stages. And because people who are hospitalized with COVID-19 tend to be much sicker than average patients, they are also very hard to save--especially when hospitals overflow. Many health-care workers imagined that such traumas were behind them once the vaccines arrived. But plateauing vaccination rates, premature lifts on masking, and the ascendant Delta variant undid those hopes. This summer, many hospitals clogged up again. As patients waited to be admitted into ICUs, they filled emergency rooms, and then waiting rooms and hallways. That unrealized promise of “some sort of normalcy has made the feelings of exhaustion and frustration worse,” Bettencourt told me. Health-care workers want to help their patients, and their inability to do so properly is hollowing them out. “Especially now, with Delta, not many people get better and go home,” Werry told me. People have asked her if she would have gone to nursing school had she known the circumstances she would encounter, and for her, “it’s a resounding no,” she said. (Werry quit her job in an Arizona hospital last December and plans on leaving medicine once she pays off her student debts.) COVID patients are also becoming harder to deal with. Most now are unvaccinated, and while some didn’t have a choice in the matter, those who did are often belligerent and vocal. Even after they’re hospitalized, some resist basic medical procedures like proning or oxygenation, thinking themselves to be fighters, only to become delirious, anxious, and impulsive when their lungs struggle for oxygen. Others have assaulted nurses, thrown trash around their rooms, and yelled for hydroxychloroquine or ivermectin, neither of which have any proven benefit for COVID-19. Once, Americans clapped for health-care heroes; now, “we’re at war with a virus and its hosts are at war with us,” Werry told me. Beyond making workdays wretched, these experiences are inflicting deep psychological scars. “We want to be rooting for our patients,” Durham told me, “but anyone I know who’s working in COVID has zero compassion remaining, especially for people who chose not to get the vaccine.” That’s why he has opted to do travel-nursing stints, which are time-limited and more lucrative than staff jobs: “It just isn’t worth it to do the job for less than the most I can get paid,” he said. He’s still providing care, but he finds himself emotionally detached, and unsettled by his own numbness. For a health-care worker, being shaken by a patient’s death comes with the job. Finding yourself unmoved is almost worse. Many have told me that they’re bone-weary, depressed, irritable, and (unusually for them) unable to hide any of that. Nurses excel at “feeling their feelings in a supply closet or bathroom, and then putting their game face back on and jumping into the ring,” Werry said. But she and others are now constantly on the verge of tears, or prone to snapping at colleagues and patients. Some call this burnout, but Gerard Brogan, the director of nursing practice at National Nurses United, dislikes the term because “it implies a lack of character,” he told me. He prefers moral distress—the anguish of being unable to take the course of action that you know is right. Health-care workers aren't quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs. Even before COVID-19, many of them struggled to bridge the gap between the noble ideals of their profession and the realities of its business. The pandemic simply pushed them past the limits of that compromise. The United States uses the rod of Asclepius—a snake entwined around a staff—as a symbol of medicine. But the pandemic suggests that the more fitting symbol might be the Ouroboros, a snake devouring its own tail. Several health-care workers told me that, amid the most grueling working conditions of their careers, their hospitals cut salaries, reduced benefits, and canceled raises; forced staff to work more shifts with longer hours; offered trite wellness tips, such as keeping gratitude journals, while denying paid time off or reduced hours; failed to provide adequate personal protective equipment; and downplayed the severity of their experiences. The American Hospital Association, which represents hospital administrators, turned down my interview request; instead, they sent me links to a letter that criticized anticompetitive pricing from travel-nursing agencies and to a report showing that staff shortages have cost hospitals $24 billion over the course of the pandemic. But from the perspective of health-care workers, those financial problems look at least partly self-inflicted: Many workers left because they were poorly treated or compensated, forcing hospitals to hire travel nurses at greater cost. Those nurses then stoke resentment among full-time staff who are paid substantially less but are often asked to care for the sickest patients. And in some farcical situations, “hospitals hired their own staff back as travel nurses and paid them higher rates,” Bettencourt said. Whatever the intentions behind these decisions, they were the final straw for the many health-care workers who told me that they left medicine less because of COVID-19 itself and more because of how their institutions acted. “I’ve been a nurse 45 years and I’ve never seen this level of disaffection between clinicians and their employers,” Brogan told me. The same is true across almost every sector of the U.S. Record-breaking numbers of Americans left their jobs this April—and then again in July and August. This “Great Resignation,” as my colleague Derek Thompson wrote, “is really an expression of optimism that says, We can do better.” The culture of medicine makes it hard for health-care workers to realize that. Most enter medicine “as a calling,” Vineet Arora told me, which can push them to sacrifice ever more of their time, energy, and self. But that attitude, combined with taboos around complaining or seeking mental-health help, can make them vulnerable to exploitation, blurring the line between service and servitude. Between 35 and 54 percent of American nurses and physicians were already feeling burned out before the pandemic. During it, many have taken stock of their difficult working conditions and inadequate pay and decided that, instead of being resigned, they will simply resign. Molly Phelps, an emergency doctor of 18 years, considered herself a lifer. Her medical career had cost her time with her family, wrecked her circadian rhythms, and taxed her mental health, but it offered so much meaning that “I was willing to stay and be miserable,” she told me. But after the horrific winter surge, Phelps was shocked that her hospital’s administrators “never acknowledged what we went through,” while many of her patients “seemed to forget their humanity.” Medicine’s personal cost seemed greater than ever, but the fulfilment that had previously tempered it was missing. On July 21, during an uneventful evening spent scrolling through news of the Delta surge, Phelps had a sudden epiphany. “Oh my God, I think I’m done,” she realized. “And I think it’s okay to walk away and be happy.” America’s medical exodus is especially tragic because of how little it might have taken to stop it. Phelps told me that if her workplace “had thrown a little more of a bone, that would have been enough to keep me miserable for 13 more years.” Some health systems are starting to offer retention bonuses, long-overdue raises, or hazard pay. And the next generation of health-care workers doesn’t seem to be deterred. Applications to medical and nursing schools have risen during the pandemic. “That workforce is apparently seeing the best of us, and maybe their vision and energy is what we need to make us whole again,” Esther Choo told me. But today’s students will take years to graduate, and the onus is on the current establishment to reshape an environment that won’t immediately break them, Choo said. “We need to say, ‘We got this wrong, and despite that, you’re willing to invest your lives in this career? What an incredible gift. We can’t look at that and change nothing.’” The health-care workers who have stayed in their jobs now face a “crushing downward spiral,” Choo told me. Each resignation saddles the remaining staff with more work, increasing the odds that they too might quit. They don’t resent their former colleagues, but some feel that medicine’s social contract, wherein health-care workers show up for one another through tragedy, is fraying. Before the pandemic, “I knew exactly who I would be working with in every single role,” Choo said. “There was a lot of unspoken communication, and my shifts were so smooth.” But with so many people having left, the momentum that comes from trust and familiarity is gone. Expertise is also hemorrhaging. Many older nurses and doctors have retired early—people who “know that one thing that happened 10 years ago that saved someone’s life in a clutch situation,” Cassie Alexander said. And because of their missing experience, “things are being missed,” Artec Durham added. “The care feels frantic and sloppy even though we’re not overrun with COVID right now.” Future patients may also suffer because the next generation of health-care workers won’t inherit the knowledge and wisdom of their predecessors. “I foresee at least three or four years post-COVID where health-care outcomes are dismal,” Cassandra Werry told me. That problem might be especially stark for rural hospitals, which are struggling more with staff shortages and unvaccinated populations. This decline in the quality of health care will likely occur as demand increases. Even in the unlikely event that no further COVID-19 infections occur, the past months have left millions with long COVID and other severe, chronic problems. “I’m seeing a lot of younger people with end-stage cardiac or neurological disease—people in their 30s and 40s who look like they’re in their 60s and 70s,” Vineet Arora told me. “I don’t think people understand the disability wave that’s coming.” Hospitals are also being flooded by people who don’t have COVID but who delayed care for other conditions and are now in terrible shape. “People are coming in with liver failure, renal failure, and heart attacks they sat on for weeks,” Durham told me. “Even if you take COVID out of the equation, the place is a mess with sick patients.” This pattern has persisted throughout the pandemic, trapping health-care workers in a continuous, nearly two-year-long peak of either COVID or catch-up care. “It doesn’t feel great between surges,” Choo told me. “Something always replaces COVID.” Throughout the pandemic, commentators have looked to COVID-hospitalization numbers as an indicator of the health-care system’s state. But those numbers say nothing about the dwindling workforce, the mounting exhaustion of those left behind, the expertise now missing from hospitals, or the waves of post-COVID or non-COVID patients. Focusing on COVID numbers belies how much harder getting good medical care for anything is now—and how long that trend could potentially continue. Several health-care workers told me that they are now more concerned about their own loved ones being admitted to the hospital. “I’m worried about the future of medicine,” Sheetal Rao said. “And I think we all should be.” A life outside medicine can be hard for people who have built their identities within it. For some, it’s like returning from war and mingling with civilians who don’t understand what you went through. “I met up with some friends who are really bright people but who said, ‘Wait, the winter was traumatizing?’” Molly Phelps told me. She thinks that “health-care workers are either preparing for work, at work, or recovering from work,” which leaves little time for talking about their experiences. And those who do talk can hit a brick wall of pandemic denial. Cassie Alexander also struggled with the fact that she was struggling. “I built my whole identity around being the toughest person I knew, and it was shattering to admit that I was broken and needed help,” she said. She returned to work last week, partly for financial reasons and partly to prove to herself that she can still do it. Others have peeled off to less intense medical roles. And some have no plans to return at all—but feel guilty about abandoning their colleagues and patients. “People going into medicine want to be of service in moments of crisis, so it was hard to watch [further surges] and feel like I was on the sidelines,” Lindsay Fox told me. Some former health-care workers have found new purpose in tackling health problems at a different scale. Sheetal Rao has helped launch an environmental nonprofit that plants trees in Chicago, especially in poorer neighborhoods that lack them. “In primary care, we focus on prevention, but that’s also about advocating for cleaner air so I’m not just sending my patients home with an inhaler,” she told me. Dona Kim Murphey, a former physician who now has long COVID, started a political action committee to get doctors into office as part of a plan to reform medicine. “I was growing increasingly concerned about how inhumane our profession is,” she told me. “There’s no culture of physicians organizing and fighting for their rights but that’s something we should think about to leverage the outrage and frustration that people have.” For the same reason, Nerissa Black, a nurse in Valencia, California, is staying in medicine. She was so disillusioned by her hospital’s handling of the pandemic that she almost left nursing entirely. But she changed her mind to continue being part of the National Nurses United union and advocating for better working conditions. For example, California is the only state that caps the ratio of patients to nurses, and she wants to see similar limits nationwide. “I feel more resolute,” she told me. Phelps, meanwhile, found the last thing she expected—a sense of peace. She used to scoff when she heard people say that you’re more than your job. “I thought, That may be true for all you nonmedical laypeople, but I am a doctor and it’s who I am,” she told me. And yet, she has experienced no identity crisis. After her last shift this September, she was on a random weekend trip with her children when, in the middle of a pumpkin patch, she started sobbing. “I realized that I was happy, and I hadn’t experienced that in almost two years,” she told me. “I’m not sure I can ever see myself going into an ER again.” from https://ift.tt/3Htl8sw Check out http://natthash.tumblr.com Imagine what it would be like to time-travel from 2019 to now. If you were just strolling down a city street, and not talking to anyone, would you even know that we’re in a pandemic? Sidewalks are no longer deserted, most pedestrians have stopped wearing masks outside, and cardboard signs praising essential workers have been thrown into the recycling bin. But there’s still one big tip-off that things are a little fishy: all those outdoor-dining setups. The tables and chairs on sidewalks and in parking spaces have been ubiquitous since the Tiger King phase of COVID-19. You can find sheds and greenhouses and bubbles and yurts and igloos and sidewalk tables and repurposed railcars and tents-that-are-outdoors-but-really-are-indoors in major cities such as Washington, D.C., and San Francisco, and in far smaller ones like Covington, Kentucky; Fayetteville, Arkansas; and Jamestown, North Dakota. New York City alone has more than 12,000 bars and restaurants with pandemic outdoor seating. Early in the pandemic, local governments relaxed zoning restrictions to let restaurants and bars assemble these (very regrettably named) “streeteries” as a lifeline. “For those restaurants where it’s possible to have outdoor dining, it’s been a saving grace,” says Alex Susskind, the director of the Cornell Institute of Food and Beverage Management. Lots of would-be diners were rightfully wary of eating, maskless, in poorly ventilated, potentially crowded dining rooms. But the al fresco option remained alluring even as the weather turned, and even in places where that meant slurping down your food in a parka and gloves. The country’s pop-up street cafés were never supposed to be around forever, but they’re one of the few measures that have lingered all pandemic long. The one thing that outdoor dining hasn’t yet weathered is this winter. Hey, what’s the point of mRNA if it’s not to free us from the torment of eating outside in bad weather? It’s been a year and a half since these plywood shanties first showed up on our streets, and now, suddenly, they’re at risk of being useless. But whether Americans decide to forgo propane-lit dinners on the sidewalk in the months to come could have effects that extend far beyond this winter. The choice we make may help reveal whether outdoor dining is just another pandemic change that peters out on its own, or a more fundamental shift in how cities divvy up their public space. To get a--ahem—taste of what streeteries will look like this winter, I called up four restaurant owners and managers who all work in different states. I heard about so many different types of heaters, I could start my own HVAC business. I heard stories about meals served last winter in arctic winds and subzero temperatures, and dread about what horrors might be yet to come. But mostly I kept hearing this: Yes, we’ll still serve customers outside this winter; but no, we don’t expect it to bring in that much money. That’s also what David Henkes, a restaurant-industry analyst at the firm Technomic, anticipates as it cools down. Outdoor dining is “going to remain in play pretty significantly this winter,” he said, “even though the urgency probably isn’t there quite as much as last year.” [Read: The total absurdity of outdoor dining structures] Stephanie Webster, the owner of Oakley Wines in Cincinnati, told me that she’s already dotted the alleyway that abuts her restaurant with heaters for maximum warmth‚ but she’s not sure how many of her patrons will actually want to linger in the cold for chardonnay and charcuterie. The temperature has already sneaked into the 40s some nights, and she has seen just one-quarter of the outdoor diners she had at this point last year. Pisticci, a neighborhood Italian joint in Manhattan, has so many tables outside that the restaurant’s capacity is double what it was before the pandemic, according to its manager, Jay Schmidt. After braving blizzards to serve diners last winter, he’s setting boundaries this year. When it gets into the 20s or below, outdoor dining will be a no-go. “At a certain point, it becomes a staff safety issue,” he told me. “I don’t want anyone slipping on the deck.” Restaurants aren’t ready to give up on street dining because, yes, plenty of Americans are still afraid to eat inside. Every week, the polling firm Morning Consult tracks public sentiments about going into restaurants. People are feeling better about eating inside now than they were in August, its surveys find, but still, as of last week, one-third of adults aren’t yet comfortable with the idea. That rate could still change quite a bit, depending on what happens to coronavirus cases, and how cold it gets, going forward. If yet another pandemic wave is on its way—unfortunately, a very real possibility—those street cafés could be fuller than you’d think. A really bad winter, though, could nudge diners through the door. “A lot of people need to rip the Band-Aid off,” Schmidt said. “Minus-12 will do that.” Restaurants already have enough to worry about without trying to model pandemic curves come January, so many are giving their streeteries and backyard patios a much-needed glow up ahead of what comes next. You’ll see lots of the threadbare blankets and barely heated wooden sheds from 2020, Henkes told me, but also more embellishments to make the experience cozier or just plain entertaining. That could mean more stunts akin to what one Bronx bar did last winter, using its allocated parking spaces to recreate the graffiti-laced interior of a subway car; or maybe restaurants will copy the example of one in a Colorado ski town, which turned old gondola cars into heated mini–dining rooms with room for eight. [Read: The dumbing down of the American restaurant] Such upgrades don’t come cheap, though. Lots of establishments have an arsenal of heaters and patio furniture from 2020, but even very basic outdoor winter dining could be cost-prohibitive for many restaurants this year. Sidewalk heaters tend to run on propane, which hasn’t been this expensive since Barack Obama’s first term as president. Webster, of Cincinnati’s Oakley Wines, told me that fuel is now so expensive that if a customer orders a $13 glass of wine and then nestles under the blue flame for an hour, she is losing money on the whole affair. If restaurants set up for winter dining, and no one comes, then what was once a lifeline for their business could turn out to feel more like a trap. With another successful winter season, streeteries may go from pandemic stopgap measure to something we expect from cities. In a few years, America’s cities might have more permanent outdoor options on every corner. Alex Susskind, of Cornell, said he envisions a post-pandemic future in which outdoor dining isn’t always available, but comes back every year when the weather is nice. But pop-up street dining takes up public space that could be used for many other things—and in ways that are more community-oriented. A few cities have already come to that conclusion, clawing back the urban landscape from tables and chairs; and the opposition is mounting in other places too. NIMBYs want their neighborhoods clear of wooden shacks. Everyone wants to dismantle nesting sites for rats. “If opponents of these sheds can point to the fact that they’re no longer used this winter, then they can point to the idea of having them removed from the public sidewalk,” said Jerold Kayden, an urban-planning professor at Harvard. “If [outdoor seating areas] are not being used, even restaurant owners won’t want to maintain them.” [Read: Surrendering our cities to cars would be a historic blunder] Street dining may even get roped into the country’s red-blue divide. Areas full of pandemic-wary liberals—and car-hating urbanites—might be poised to keep streeteries around a while longer, while red areas that are already back to normal ditch them for this winter and beyond. That would track with the restaurant recovery as a whole: Establishments in states that voted for Donald Trump in 2020, such as Oklahoma and Kentucky, are doing better relative to 2019 than those in states Joe Biden won, such as California and Illinois. Ultimately, this winter is the make-or-break moment for where outdoor dining goes from here. If customers are willing to endure sitting in the cold this winter, then streeteries are likely to endure through next spring and summer too, and maybe into the fall of 2022. At that point, they’ll have more than two years’ worth of squatters’ rights on city streets, and a chance of staying longer. from https://ift.tt/3FhGiYt Check out http://natthash.tumblr.com |
Authorhttp://natthash.tumblr.com Archives
April 2023
Categories |