Monitoring the patient with chronic kidney disease -- my ABFM QI project criteria

Every three years I have to do a quality improvement project to maintain my family medicine board status.  This year I decided to focus on my patients with moderate chronic kidney disease. I have access to a report that identifies the patients of interest so all I need to do for the project is upgrade their care.

To do that I had to put together a list of things to do by reading the short "pocket card" version of the VA/DoD care guidelines (I'm too lazy to read the entire long thing). I then ran it past a friend who is a leading research nephrologist to comment on which of the guideline actions were really valuable.

I liked the result so much I'll share it here. The numbered items are what I took from the guidelines, the comments in () are his corrections, the comments in [] are my later thoughts. I think it's most interesting to read with both, I added emphases: 

As of Dec 2020:

1.       Measure urine alb/cr ratio yearly (sure in people with diabetes not on ace/arb)

2.       Measure Cr yearly (ok- not great evidence) [U/A, micro albumin, Iron]

3.       ACE/ARB for all but not both (if htn and/or microalbuminuria – or chf) [so implies measure for microalbuminuria along with yearly Cr]

4.       Oral iron therapy (if iron deficient, or starting epo) [so, contra guideline, not routinely, but implies check iron yearly?]

5.       If Hgb < 10 consult for erythropoietin (I’d wait till < 9 – no evidence for greater)

6.       DM

a.       Evaluate metform if CrCl < 40 (ok)

b.       SGLT-2 (empagiflozin, etc) inhibitor if stage 1-3 and DM (can go down to egfr of 30)

c.       GPL-1 agonist (liraglutide)  (no good evidence beyond sglt2) [contra guideline]

7.       If GFR < 60 then BP < 140/90 (I think this would be for most people)

8.       Do cystatin-C GFR one time (never unless paraplegic or loss of muscle mass – amputation) [contra guideline]

9.       If not Diabetic need at least one renal imaging study [I made this one up, but seemed to follow] (sure)

10.   Apply Kidney Failure Risk Calculator (Navdeep Tangri, MDCalc) (sure)

11.   Stage 3 and above: dietary consult

a.       Bicarbonate supplementation if metabolic acidosis (if bicarb < 18)

b.       Dietary sodium restrictions (yes – for all those with htn)

c.       Protein 0.6-0.8 g/kg/day (skip this one – good evidence – hard to do) [Curbsiders had recent podcast saying same]

12.   Stage 3 and above need a PTH measured (never measure pth in ckd unless hypercalcemia) [contra pocket card guideline so many a mistake in that] 

Biden's lost agenda

In the Fall of 2020 the American people decided to dump Trump. Americans didn't agree on much else; voters rejected significant change. Overall the result did not surprise me, especially given the summer riots and the "defund the police" movement.

Biden's agenda is mostly history. Except for the most important part. I'm going to get to that in a future post (it's not student loan forgiveness!), but first I want to reference the future America rejected. I'll use George Packer's summary in the Oct issue of The Atlantic (emphases mine):

America’s Plastic Hour Is Upon Us

... The scale of Biden’s agenda is breathtaking. At its center is a huge jobs program. A Biden administration would invest $2 trillion in infrastructure and clean energy. He proposes creating 3 million jobs in early education, child care, and elderly care—sectors usually regarded as “soft” and neglected by presidential candidates—while raising their pay and status. “This economic crisis has hit women the hardest,” Sullivan said. “These care jobs are primarily jobs filled by women—and disproportionately women of color and immigrant women—but they don’t pay a fair wage, and the opportunities to advance aren’t there. This is a big, ambitious, bold proposal—not an afterthought, but at the core.” Another $700 billion would go to stimulating demand and innovation in domestic manufacturing for a range of essential industries such as medical supplies, microelectronics, and artificial intelligence. Some $30 billion would go to minority-owned businesses as part of a larger effort to reduce the racial wealth gap.

Biden is proposing industrial policy—massive, targeted investment to restructure production for national goals—something that no president has openly embraced since the 1940s. His agenda would also give workers more power, with paid family and medical leave, paid sick days, a public option for health care, and an easier path to organizing and joining unions. It would more than double the federal minimum wage, to $15 an hour ...

Ok, that's the agenda that was. Wave good-bye to it, but don't give up entirely. There's something in there that can be saved.

What is middle class and what percentage of American voters can't get there?

What would make someone "middle class" in 2020?

I like to think of this in terms of what a "middle class" 30 yo adult should have or be able to do without inherited wealth [1]:

• basic health, life, dental, and disability insurance.
• enough savings to live without income for 3 months.
• at least two weeks of vacation a year plus holiday
• ability to take the family on a local or auto based holiday
• cover the basics: food, utilities, broadband, mobile phone, automobile, two laptops, a game console, netflix, a bicycle
• together with a partner
• enough income to cover a 15 year mortgage on an average American non-urban home with good-enough public school services
• enough income to raise up to two children to adulthood (but not pay for their college -- that's upper class)
• a second car

That's not a comprehensive list, but I think it's not hard to fill in the rest. Things that are often beyond middle class include:

• international travel
• paying for children's college education
• a short commute
• weekly restaurant meals
• multiple bicycles
• substantial savings esp. retirement savings
• routinely buying work lunch
• multiple streaming services, cable TV
• a subscription to the New York Times digital services (this is a problem)

How much compensation, including income and benefits, does it take to be middle class today?

In the absence of good data my impression is that a new teacher is at the very bottom of middle class (compensation increases over time). Salary.com says the range for all teachers is $50K-$74 plus. Add on benefits that are worth at least $10K and the entry to middle class America in 2020 is probably $60K for an individual. 

A 2014 Pew report article on "middle income" estimated that "a three-person household would have to earn between $42,000 and $126,000. I believe that number omits benefits so it supports my $60K compensation number as a good reference. 

For a 50 week year at 40 hours a week a $60K/year compensation works out to about $30/hour or twice peak minimum wage. Google tells me the hourly wage for a plumber or electrician is about $25/hour, enlisted American soldiers get $20/hour but with benefits and allowances for food, housing, etc they may be in the $25 range. In 2000 motor vehicle manufacturing workers made a similar $20 hour, with benefits that might get compensation up to $22/hour. In US government a GS-7 level is about as high as one can get without a college degree and it maxes out at about $50K/year -- just barely middle class given benefits.

All of these are below my "middle class" threshold though federal employment comes closest.

It's hard to make it into the American middle class range without a college degree or some degree of business ownership [2]. Since no country on earth has gotten much more than 50% of young adults through college this means a middle-class-or-better life, which still comes with quite a bit of economic stress and uncertainty, is only available to about half of Americans.

Half of US voters unable to attain the basics of the bottom of the middle-class is not a politically viable situation. More on that in a post that updates this one.

- fn -

[1] If you live in American for a while it eventually dawns on one that a lot of white folk inherit a substantial amount of money. I'm excluding that from this definition but it does explain some unusual consumption patterns.

[2] Bruce Springsteen, Bill Gates, Steve Jobs, Wayne Gretzky, yada yada ya. Don't make me come down and bop you.

How I think about the Trump voter and America

A few days ago I listed about 25 reasons that Donald Trump should not be President. Any one of them is sufficient by itself.

There are lots of lists like that. Every science and reality oriented publication in America had its own list. All opposed Trump. All recognized that beyond his venality and incompetence democracy was also at stake.

And yet ...  he almost won reelection. The GOP held the Senate. Dems lost some House seats. The polls were wrong again (I blame the iPhone for the polls - ask me why).

So what do I think about America in general and the Trump voter in particular?

America is what it has always been. Some decades it does better, some worse, but in general it's a rough neighborhood. We were born from slavery and genocide, we fight lots of wars, we don't have universal healthcare, we tolerate mass shootings of children, we have large majorities that support torture of prisoners, we fund public education with local taxation and college through massive debt, we tolerate systemic anti-Black racism, we allow suppression of Black voting, we reelected GWB despite his torture program and the misdirected conquest of Iraq. We did well with higher education and science for a while, but the GOP attacks on science have done grave damage.

We aren't the worst of nations. China, Russia, North Korea, Germany in the early 21st century ... there are lots worse than us. We aren't the best of nations. Canada, the Nordics, South Korea, most of Europe, Japan are all better. Among post-industrial nations we are probably somewhere in the bottom third, but I could maybe argue for being average. Which makes sense -- we are made of humans and we're big and diverse enough to have a representative sample. Our Presidential system and electoral college and our history drive us down a notch or two.

That's America. What about the Trump voter?

I divide the Trump voters into slices. The biggest and most important are the "White* Left Behind". They are a diverse group, but in general they do not have the cognitive traits to be a "knowledge worker". They did not attend college and college would have been a poor use of their time and money. They don't read newspapers, they don't reason out their vote, they vote based on tribe and emotion. They are more or less anti-Black racist but they don't think they are being unfair. They are desperate to work but there are few good jobs for them. Living in an increasingly high tech and complex world they are every day reminded that they can't keep up. They live on the edge.

Trump's genius was exploiting the WLB while showing them that they have real political power. I don't blame the WLB for voting Trump. They are as much victim as they are aggressor.

The religious fundamentalist is another slice. A complicated slice. For some religion is a shallow facade they may assume or discard as needed. Others have a deep conviction that to me shades into delusion -- but I respect delusion. The universe is a vast and terrible place dominated by violence and entropy -- we all need some delusion. If you believe that every terminated ovum is a murder, and you know Trump will suppress abortion, then that outweighs all his other crimes. You might even decide to worship him. 

I don't much blame the religious fundamentalist for voting Trump. They may be rationally choosing based on their fixed belief.

That leaves those who are not dominated by religious belief and who won enough of the cognitive lottery to be able to read newspapers, to remember what happened weeks or months or even years ago, and to make an informed decision.  They may feel that democracy is hopeless, that authoritarian rule is inevitable, and they want to be on the side of the winner. They may care only about their wealth and privilege and feel Trump will best defend them. They may be fully racist -- generally anti-Black racist rather than pan-racist. (Anti-Black racism is far from a White-only thing.) They may enjoy living in an authoritarian society where they are commanded by superiors and able to command the inferior.

They are the elite Trump voter. I blame them. They have chosen a wrong path. They can redeem themselves in future, but for now I cannot be their friend.

* As of 2020 American "White" may include Latino/Hispanic. That boundary has long been fluid.

The Trump I remember

It's Nov 6, 2020 and I believe Trump's presidency is ending. I look forward to forgetting him, but one day I'll be asked what all the fuss was about.

For that day, to remind me, here is what I know of him know:

1. The crimes for which he was impeached -- extorting a foreign power to attack a political opponent.
2. The crimes for which he was not impeached -- the collusion with Russia against HRC.
3. The obstruction of justice.
4. The personal corruption.
5. The corruption of government and of industry, including running a protection racket against businesses.
6. The casual racism.
7. The people who worked for him.
8. The anti-science -- from CO2 to COVID to the environment and beyond.
9. Inserting Christian fundamentalism into American government.
10. The constant lying. (He was paradoxically transparent however. An accusation was invariably a confession.)
11. His mockery of persons with disabilities.
12. The threats and the cruelty. Not least the separation of migrant children and parents.
13. The stupidity. He really didn't seem to know very much about anything beyond corruption and real estate.
14. The propaganda.
15. The destruction of the ACA without a replacement.
16. The complete disinterest in art, culture, and the humanities.
17. The destruction of government agencies.
18. A complete lack of honor, compassion, or decency.
19. COVID mismanagement.
20. QAnon.
21. The authoritarianism.
22. The pardons. (Remember Al Kinani)
23. The post-election conduct.
24. The record-breaking federal executions.
25. The Gallagher war crime pardon
26. The illegal destruction of government records. 

As of Nov 2020 McSweeney's has a list, NYT Magazine did an interactive summary, The Atlantic had many articles summarized in their Biden endorsement:

...he has divided our people; he has pitted race against race; he has corrupted our democracy; he has shown contempt for American ideals; he has made cruelty a sacrament; he has provided comfort to propagators of hate; he has abandoned America’s allies; he has aligned himself with dictators; he has encouraged terrorism and mob violence; he has undermined the agencies and departments of government; he has despoiled the environment; he has opposed free speech; he has lied frenetically and evangelized for conspiracism; he has stolen children from their parents; he has made himself an advocate of a hostile foreign power; and he has failed to protect America from a ravaging virus"

Was there anything he did that was good?

1. Accepting North Korea as a nuclear power. It was the only viable choice, but I'm not sure HRC could have taken it (esp. with a GOP Congress).
2. He understood the Left Behind -- the majority of Americans who will never be knowledge workers. I don't think my team gets this. He didn't know what to do for them, but he knew what they wanted.

Update 1/18/21 - adding Unthinkable from The Atlantic.

What I would add to the standard blog model

The combination of RSS and the basic blog post is almost perfect. There are, however, a few things that would make them even better as a way to share information in most organizations.

1. Provide an email summary option that is generated on post, daily, or weekly. (SharePoint does this for some list types.)
2. Add a Publication Date in addition to the Last Modified date and make the Publication Date both the primary sort field and make it user editable without changing the URL. That way a publisher can choose to easily replace a topical post with a newer version and optionally republish it as new. (For organizational use the historical record is unimportant.)
3. Author control of notification generation. There's no need to generate a fresh RSS entry or email update for the correction of a few typos or other minor changes.
4. Easy sharing of articles by email and other 'send' modalities.
5. Tags with tag specific rss and views (many blogs do this).
6. Editing tags should not generate notifications.

That's all. No comments -- in practice I think these can occur elsewhere.

PS. It looks like Blogger has broken tags/labels as of today! So this post has none.

Electric vehicles will end another non-college job - the auto mechanic

 My Great-Aunt was born in the 19th century. She spent most of her life working in data processing. She, and thousands like her, did read, delete, update operations on paper cards that were passed between thousands of small rectangular desks in a large rectangular building in Montreal. None of her coworkers had a college degree -- I suspect many could not read very well. The work seems impossibly dull, but she enjoyed it and the pension it brought her.

I have one of those desks, I'm typing on it now. It fits nicely in a corner of my living room, and I'm slender enough to fit comfortably in it.

By the 1960s the first business computers wiped out her industry as definitively as the automobile eliminated millions of horses. There would never again be a large scale job that required no particular social, physical, or cognitive skills.

Since that time IT has generated vast numbers of knowledge worker jobs that pay relatively well while eliminating jobs that do not require cognitive skills.

Now electric vehicles are going to do the same thing. Compared to internal combustion engines they are much easier to maintain; their complexity is in batteries and software. Never-college auto mechanics are going to lose their jobs.

There's a lot we can do about this problem. It's not only the right thing to do, it's also essential to our survival. Even if Biden wins in 2020, if his administration doesn't act quickly there will be another Trump in 2024.

State of the COVID-19 Pandemic - Fall 2020

I've written only a few COVID-19 posts, mostly about masks and activities. Looking back at them today they hold up pretty well. This feels like the right time for a summary.

Obviously the American response has been pretty lousy. Given America's fissiparous culture and lousy record on things like managing gun violence and providing universal good-enough healthcare we were never going to do a terrific job, but Trump took us down a few more levels. The GOP's anti-science and anti-government stance has contributed as well, not least by underfunding the CDC for decades. It does suck that the disease is infectious before symptoms develop.

We will probably get a decent vaccine. Even if Trump, Xi, and Putin screw-up their national evaluations there will be a few nations that do it right. We probably won't get a great early treatment antiviral in the next year or two but our hospital management will keep incrementally improving and we ought to get a decent monoclonal. We are, despite America's almost incomprehensible incompetence, starting to see better masks in use. Masks that protect the wearer as much as they reduce spread. (We could have lightweight PAPRs for use by vulnerable teachers, but that's like asking for a warp drive.) We should get inexpensive antigen tests for use in school and home, and we'll probably figure out how to use them.

Our understanding of the American pandemic is not great. Data is getting harder to find for many states. That won't change unless Trump loses -- and even then it will take months to rebuilt. A few states may have good data collection so we will have to rely on them to sample pandemic progress. Universities and non-profits are trying to close the gap. Getting local prevalence data in Google Maps will help. There's still a chance states will adopt Google/Apple contact tracing (paging Minnesota, damnit).

On the bright side our knowledge of the innate immune system and of viral infection sequelae (myocarditis [1]!) is growing ten times faster than normal. Even in the QAnon world we can still do some science.

On the public front the situation is mixed at best. It will be a miracle if we don't see a big rise in numbers as winter settles in and we move indoors. Pandemic social and economic distress is amplified by the longterm issues of never-college income, information technology disruption, demographic shifts, and the legacies of American slavery. Remote work has been pretty successful though -- getting people out of air conditioned offices is a big deal.

Less unhappily, unknown sequelae aside, the vast majority of people under 40 with good innate immune systems seem to tolerate SARS-CoV-2 pretty well (though some will die horribly after months of struggle and the myocarditis thing is a bit worrisome). It also seems that a modest amount of ventilation dramatically reduces infectivity -- and, despite lack of public guidance and Trump's CDC sabotage, I think ventilation is improving. There don't seem to be big outbreaks in gyms or ice arenas for example -- though there's also no useful data. COVID-19 will become endemic, but over decades, as we develop true herd immunity, it will become more like the other coronavirae that we live with.

Between our various failures, residual strengths, and the peculiarities of COVID-19 much of America is more-or-less implementing some version of slow motion infection of the under 30 and more-or-less leaving the 40+ to protect themselves. The elite 40+ segment of Americans are learning to buy and wear user-protective masks, the non-elite are kind of screwed. But that's America in the year 2020.

- fn -

[1] Lots of people are wondering how common myocarditis is with viral infections. We've always known of viral myocarditis, but it's not like we did cardiac MRIs on everyone with a cold. The decrease in MIs during COVID precautions is certainly interesting. This review isn't perfect, but it's a good start.

FDA "approved" KN95 masks available on Amazon - $4 each

In my various explorations of next-level masks I found this one on Amazon (Via Rolling Stone, the acting public health division of the US government [1]):

https://www.amazon.com/Powecom-Protective-Non-Medical-Efficiency-Authorized/dp/B087M2T7NP

Currently $4/each with Prime. That price is typical for next level masks, prices are falling fairly quickly though.

Powecom shows up on the FDA n95 alternative list: Appendix A: Authorized Imported, Non-NIOSH Approved Respirators Manufactured in China (Updated: August 14, 2020) as Guangzhou Powecom Labor Insurance Supplies Co., LTD

We keep these for higher risk situations, such as visiting people even older than us (apparently they exist) or taking a drive share ride.

I think availability is rising quickly and prices are falling, I expect they'll drop below $3/mask in the next  few weeks.

After months of seeking better masks we are now getting the sort of thing China has had since January. We are learning about our options not from the failed American state, but through the efforts of the last remnants of American journalism.

MAGA.

[1] Contrary to this article physicians reuse N95s. We wear them one day, leave them in a hot dry place for a week, and wear them again.

COVID Cancellation: The fight with Delta from May 1 to Aug 20, 2020

The COVID battle with Delta

1. May 1, 2020: Delta canceled a flight for daughter and I to Korea. I spoke with the Delta rep and was told we'd receive a full refund. But trouble was already brewing.
2. We were in Delta database for refund until, one day, we were not.
3. We sent complaints to DOT, MN Attorney General, and American Express
4. July 11, 200: American Express responded to our objection and refunded two tickets.
5. DOT said they'd referred our complaint back to Delta.
6. Delta refunded ONE ticket
7. American Express reversed their refund on both tickets. I tried to appeal but the appeal process said I had to phone (which is very hard to do on my schedule).
8. I replied to the DOT and Delta/DOT email addresses that one ticket remained. 
9. I was unable to get more help from AMEX. 
10. Aug 20, 2020: Delta notified a second refund and a few days later it was in my AMEX account.

There are class action suits against Delta and other airlines. Our struggle went on for almost 4 months.

My guess is Delta was managing its cash flow by paying its debts slowly. I suspect high mileage customers with flight insurance received early refunds -- because Delta knows the insurance companies would go after them. Then high mileage customers and major business buyers. After that it's who complains the most and longest. 

Delta fought payment pretty hard. I though it was over in July when AMEX refunded us, but I saw the paperwork Delta sent AMEX. They really didn't want to pay. 

In the end I think the DOT complaint did the trick. I never heard from the MN state attorney general.

I hope the class action suits succeed.

Curbsider CME for non-internists through VCU Health

My favorite CME source, the Curbsider's Podcast, has long offered CME credit for internists (they are, after all, an internal medicine podcast). For family physicians, not so much.

There is now to get free Category One AMA credit [2] for Curbsiders podcasts through "Virginia Commonwealth University's VCUHealth Continuing Education [1] using their Curbsider curriculum.

You have to listen to the episode and complete a post-test. You can and should use the Podcast notes to compete the post-test (how we learn). 

I was able to register with VCUHealth although I have no connection there. After registration I completed my profile. (The web site is ancient and barely works in a modern browser -- don't try it on mobile.)

This is all a bit of a secret. I only know of it from a blurb at the start of recent podcasts. There's a tiny CME link to VCUHealth at the bottom of the summary page for recent episodes.

I've completed one module. There were 3 post-test question, one didn't have a clear answer (practice varies). On answering all 3 "correctly" I received a certificate. I had to answer some annoying 'commitment to change' survey questions that must be part of a (past? forgotten?) VCUHealth initiative. I received a link to an AMA PRA category one certificate that I downloaded, then I entered the CME at the ABFM site (they had entries for VCU).

A happy discovery. Thank you VCU and Curbsiders.

- fn -

[1] Starting from the CME site, it was weirdly hard to figure out what the heck VCU is. The logo is really small and the full name is never used.

[2] To be a AAFP fellow you need AAFP CME, but the American Board of Family Medicine accepts AMA Category one and their own programs. The two organizations don't entirely get along. 

Update 5/1/2023: I once completed a "knowledge feast" CME from the Curbsiders that spanned multiple episodes and was very (maybe too) time efficient. I believe that was a one time thing -- too easy to misuse I fear.

Viktor Frankl - on expectations and the behavior of people

Viktor Frankl formed some of his opinions of human nature by surviving several concentration camps. After his release, in a few days, he wrote a book about his experience - Man's Search for Meaning.

The book has harsh critics. I read it and I think much of sees truth, though it also a book of another era -- an era in which "man" more or less included women. 

Today psychology, psychiatry, neurology and the sciences retain little of Frankl's life work. He could not grasp that meaning might exist in the absence of religion, or that responsibility could be assumed rather than fundamental. I believe, however, that he had a true understanding of the extremes of human nature for evil and for good.

YouTube (and the Ted site) have a video of a lecture he gave later in his life. From the Frankl Institute (with let another video copy!):

YOUTH IN SEARCH OF MEANING, 1972 [4:22]

Frankl speaking at the "Toronto Youth Corps" in 1972. See Frankl "at his best" as he vividly explains his theories, and even draws analogies to piloting an aircraft – a passion he had recently picked up.

In this lecture he talks about how one must "crab" an airplane to adjust for a crosswind (1:45).  To reach a destination you have to periodically turn into the wind. He expands the analogy to people:

If we take man as he really is we make him worse. But if we overestimate him ... if we seem to be idealist and are overestimating ... overrating man ... and looking at him up high ... we promote him to what he really can be...

... Do you know who has said this? If we take man as he is we make him worse, but if we take man as he should be we make him capable of becoming what he can be? ... This was not me. This was not my flight instructor. This was Goethe.

From this it is a small Google step to the Goethe quote (in English):

When we treat man as he is we make him worse than he is.

When we treat him as if he already was what he potentially could be we make him what he should be.

 In the strange time of June 2020 I think this is worth remembering.

The mask we need

What do we believe now?

We think that coronavirus is moderately contagious and is spread primarily from person to person rather than by surfaces to person. We think the best way to get COVID-19 is to join an indoor dance and singing session and that outdoor spread is rare. We think indoor masks are valuable and outdoor masks are primarily social gestures. We think cloth masks work primarily by reducing spread from someone with early COVID-19 and minimal symptoms. As of today there's a suggestion that children get mild COVID-19 infections but don't spread them well.

We believe social distancing reduces spread but has a terrible economic cost that falls primarily on non-college workers and small business owners.

We believe effective therapies will emerge gradually over the next 4-18 months and effective vaccines over the next 6-18 months.

So what could we do now that would reduce infection, possibly suppress disease, and allow the economy to reopen?

We should test and trace of course, but given the state of American government and American media (Fox, Murdoch, etc) that's unlikely to be enough.

So what else could we do that doesn't require new technology or new innovation?

We could give every adult a better indoor mask. A mask that gives bidirectional protection, that protects against both infection and transmission. Give it first to 70+, then 60+, then every adult.

What are the features of this mask?

It's reusable of course. Washable with a filter module that's easy to replace. It comes with a UV light sterilizer than can hold several masks. It's a high air flow mask; you can wear it to your indoor CrossFit speakeasy and get your deadlifts done. It's not medical grade, but it's a hell of a lot better than a surgical mask.

If you're going to wear a damned indoor mask, it should work.

This doesn't require new science. It doesn't require new technology. It doesn't require closing the economy. At $100 a unit we could give every American adult this mask and a family UV sterilization unit for 30 billion dollars.

30 billion dollars. That's nothing. Jeff Bezos could do it from his change pocket.

Want to restart the economy?

Make this mask.

Wearing a cloth mask outdoors is like wearing a helmet in your car

I wrote this first on Twitter:

Outdoor masking is the equivalent of wearing a helmet in your car. Indoor masking is the equivalent of wearing a seatbelt in your car... 

 ... Formula 1 drivers wear helmets in their cars. Makes sense for them. For rest of us net gain is just background risk noise... 

... It took decades of struggle to get Americans to use seatbelts. Even now some don’t. Despite overwhelming value... 

... If you get hung up on wearing helmets in cars people will think you are nuts and ignore the seatbelts.

The best science I've seen on outdoor communication is the Chinese tracing analysis. We aren't going to see much more science -- experts consider the risk too low to be worth researching given all we don't know about indoor transmission (including transit).

There are two valid objections I know of to this stance:

1. Outdoor masking is of low value but it helps set social expectations that make indoor masking acceptable.
2. If you don't wear a helmet in your car the risk is on you, if you don't wear a mask outside the risk is on me.

To which I would say - True. But ...

1. We would never have gotten seatbelts in cars (high value) if we'd insisted that helmets were equally important (much lower value). If we don't have science we have nothing against the forces of stupidity.
2. Yeah, that does suck. Happily the risk to you is extremely low. As a matter of politeness we should give anyone wearing an outdoor mask a 10 foot space. It's a signal of strong personal concern.

Outdoor masking has a cost beyond damaging expert credibility. It's very uncomfortable to exercise wearing a cloth mask. The physical and mental health benefits of exercise dwarf the non-existent value of the outdoor cloth mask.

Indoor masking is where we should be putting our energy. We should be developing N95 equivalent reusable masks for at risk persons to wear indoors in place of the cloth masks most of us wear.

True story. My father, who was a geek before his time, specced seatbelts on his 1950s company car (to the chagrin of his boss no doubt). They came as 4 point restraints. When he showed up in the car for a date his guest refused to enter the car. Anyone with seatbelts in the car must drive like a maniac.

PS. Regarding those "outdoor plume" studies --- viral reproduction does not scale with respiration. That is, if you breathe 3 times as much you don't exhale 3 times as many viruses.

The year ahead

Massachusetts is going to try the Wuhan/South Korea path. Or something like it.

What's the alternative?

1. Shut down and open up -- trying to stay under healthcare capacity.
2. Buy time to find meds that work a bit, better care approaches for outpatient, hospital, ICU. There are some that look promising now (not HCQ).
3. Buy time to build up manufacturing, supply chains, new jobs in COVID-19 care and management, serology that actually works.
4. In a year or two we have some vaccines that work like those developed for animal COVID.
5. COVID becomes a second yearly severe flu, worse than the Swine flu. On top of the traditional flu.
6. We have fewer people over 80.
7. Many countries will stop Americans from visiting.

In Minnesota we'll let Georgia make the mistakes. If Massachusetts succeeds we'll try that.