Knock-On Effect of "Forgetting" Germ-Theory of Disease?

It sends me around the bend when someone, often unthinkingly, nods to the belief that being in cold air, especially without a jacket, may lead to catching a cold. As opposed to what actually causes one to catch a cold--being exposed to cold-causing germs (many rhinoviruses, some coronaviruses).* Many/most such people know better, they are just forgetting the basics of germ theory of disease.

It seems relatively harmless, but then again, maybe mis-apprehension of basic science, when widespread across society, weakens resistance to intellectual contagion. I am absolutely NOT saying that average person who conflates cold exposure with cold transmission is in the RFK camp. Just that misunderstanding facts and science can never be assumed harmless.

(*Yes, there are things about cold weather that make cold germs more likely to assault a person, but that is completely different than mere exposure to cold. But that correlation, and the simple fact that we have named the illness "a cold", does a lot to fuel the confusion.)

I always assumed respiratory viruses were primarily airborne

Must have been a case of being right by dumb luck, but my mental model of respiratory viruses (influenza, colds) was that they were primarily transmitted by inhaling particles in the air--not by having projectile droplets land on your facial orifices.

 

Breakthrough Is a Bad Choice of Words

TL;DR: "Breakthrough infections" is a misleading term, let's not use it. Not sure what the ideal term is, maybe post-vax infections.

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I wish we would stop referring to cases where fully vaccinated people get Covid as "breakthrough" infections. That term has strong suggestion that the primary cause of infection is that a variant strain of Covid has become fully vaccine-evasive. 

Variants do muddy the water a bit, but let's set them aside for a moment. No vaccine is 100% effective. The wide range of available Covid vaccines are quite effective, with the predominant ones used in the US, Pfizer and Moderna, being an astonishing 95% efficacious. Which, reminder, means not that 5% of vaccinated people are destined to eventually get Covid; but rather, the incidence of getting Covid will be 95% lower in vaccinated people.

So, variants aside, the efficacy rate indicates that there will always be some fully vaccinated people who get Covid. Why? The vast majority of the time, it is because, for one reason or another, the vaccine did not generate an adequate immune response. Sometimes because the person is already immunocompromised (more likely if elderly, or if on immunosuppressants, or perhaps exposure to a massive viral load), but also sometimes happens for other reasons to younger, healthy people.

My point: in those cases, nothing has been "broken through" by the nasty Covid virus. Rather, there was no strong defense in place, Covid waltzed right into their body. No breaking was required. This no more involves breaking-through than a non-vaccinated, immunologically "naive" person getting Covid.

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Okay, now about the variants. It is true that some of the variants are better able to evade the immune response of vaccinated people. But the immune response in general is not like a levee that is either breached or holds (excellent article from Zeynep that explains this). And the immune response from the vaccines is particularly massive. So while variants to-date may be somewhat more likely to cause a breakthrough post-vax infection, that is incremental--it is not the main explanation, and hence it is misleading to refer to it as a breakthrough phenomenon.

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Another thing that should be emphasized is that even when breakthrough infections occur, the severity is markedly less. Many are entirely asymptomatic, and found only by random testing. Others are very mild. The efficacy of vaccines against severe Covid and death is stunningly high, in the 99+% range. That gets back to the flawed levee analogy, and also maybe the nature of Covid variants, as compared to other things, especially the familiar disease-resistant antibiotics. It it much less all-or-nothing. A person with a weaker response, or a variant that is more vaccine-evasive, usually involves far less risk of a dire outcome than for an unvaccinated person.

So variants are worrisome, but not cause for panic. Of course, the more people that get vaccinated, the less change for variants to emerge. 

In the meantime, let's stop referring to post-vax infections are "breakthrough".

Face masks Phase II

KN95 Notes

CDC testing results (scroll down, expand + sign to see list).

CDC updated results

Here are some articles on fakes (1,2,3). They are on Medium, so I can't be 100% certain of the author's bona fides.

I have been using Purism for 5 weeks. They were originally on the approved list, as of 09/22/20 on the "no longer authorized" list. But they did very well in the original testing, so I think the no longer authorized means that they didn't quite meet the highest standards, but they are still much better than any random paper or cloth mask. They go in and out of stock. When available, I have seen them 20 for $40. They passed the "blow out a flame" test and the "holds water" test. They are durable, and have held up very well to repeated wearings. The ear loops are definitely on the tight side (I have a really big head), but that is more a feature than a bug, b/c they have to be tight to be effective.

Do not be put off by the price. $2 per may be very inflated compared to pre-Covid prices, but well worth it. Honestly, given how quickly paper masks deteriorate, these may be cheaper in the long run. I have one that I keep in my car. I have probably donned and doffed it 50 times, and it is still in great shape. 

I also bought some Holodeal, when Purism were out (just to have more--I have been handing them out to family). They seem equally good, but I have less wearing experience, and couldn't find the brand rated. Price about the same.

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In the USA, we have more or less gotten to the point where most evidence-oriented individuals understand that face masks help stop the spread of Covid 19.

But not all face masks are equal in effectiveness. It certainly *does* seem the case that even make-do face masks have significantly over-performed. But we are past the extreme shortages of PPE, and KN95 masks--arguably as good as N95, so long as they are genuine--are available.

I have been using KN95s for over a month. They seem very good. I subjected my batch to a few of the tests to detect counterfeits, they passed. They are maybe 20% harder to breathe through. The an offsetting benefit, at least for me, is that they form a peak in front of the nose. Whereas the flat masks seal against my nose when I inhale.

A well-fitted N95/KN95 is theoretically a total Coronavirus barrier, whereas make-do masks inhibit viral load, but don't reduce it to zero, so they buy time, but cannot absolutely prevent transmission.

My point is--let's not rest on laurels. Let's up mask-wearing to the super-effective masks.

(A bonus--although they are more expensive, they are much higher quality, so last through many, many wearings. Unlike the cheap ones, which tend to break a strap the first time I fiddle with them!)

Covid-19 Risk Is Respiratory

It is shockingly hard to get people to absorb basic public health facts related to Covid-19.  Most fundamentally, that is is 95-100% RESPIRATORY. So handwashing and face shields can't hurt, of course, but the risk is that they are a distraction that creates a false sense of security(1). Zero surprise that this Swiss case investigation found face shields didn't confer much protection, while masks did. 

Another point that has been massively and unnecessarily confusing is the idea that "the (sole/main) reason to wear masks is not that they protect the wearer, but that doing so is a pro-social act to protect others". While the protect others part is certainly true, I am baffled as to the belief they don't also protect the wearer(2). Good to see this article take on that point.  

(1) The false sense of security factor was, I believe, one of the reasons masks were originally downplayed by some public health experts. Best of intentions, probably, but clearly a devastating mistake, in hindsight. 

(2) It may come from the established practice in some countries, mostly east Asian I think, of wearing masks when one is sick, yes, in order to protect others.

I went for PT recently and it was pretty helpful. Each week for 4 weeks they gave me additional exercise. They sent me home with printed diagrams like this (random link, not my actual exercises). Exercises seemed to help. What I wish they had also given me were links to each of the recommended exercises. Ideally, all compiled into a personal master URI for me, for my future reference if needed.

Fat-Burning Heart-Rate Zone

Nice to see this article explain how the "fat-burning zone" is utterly misconstrued and generally bs. When it comes to diet or exercise, I've always been a believer in calories-in, calories-out.

And as a lifelong, daily exerciser, I've always thought the heart rate obsessions was a silly, fiddly distraction, unless you are a semi-pro or better. If the time spent measuring and logging heart rate were just spent exercising more, you would be way ahead. 

Example of Doc *Not* Disabusing Patient of Placebo Belief

I'm always interested in placebo effect and in particular, the ethics of leveraging it. Here is an interesting case of a doc explicitly speaking to his approach of not warning a patient off a benign placebo:

On the other hand, Felson says he doesn't disabuse patients of the notion that the supplements are helping if patients truly believe they are, even though a month's supply can cost $30 to $50. "Far be it from me to take away either the placebo effect or an idiosyncratic reaction that might be of benefit," he says.

Fadwatch: High Intensity Workouts

a few minutes of any strenuous exercise is sufficient to improve various measures of health and fitness.

Prediction: super-high-intensity workouts will be a fad. Reminds me of the publicity, a few years back, that insinuated 30 minutes a day of puttering in the garden was about as good as a regular exercise routine.

Not to mention, the people attracted by very short, very intense workouts are not the kind of people who will want to endure the pain they involve.

It Is SO Easy to Donate Blood

Within the United States, an ever-growing number of people are ineligible to donate blood, due to medications and travel restrictions. Of those who are eligible to donate, only 5% do so. It's really easy, for many eligible donors, I think inertia and inconvenience are the main barriers. Herewith are my guidelines for painless blood donation:

PRO TIP: It is a great excuse to indulge yourself in a big meal. The first two times I gave, it was in the morning on an empty stomach. I almost passed out. I didn't give for the next 5 years. When I finally tried again, it was an afternoon appointment. I had happened to go to an all-you-can-eat buffet beforehand. I gave, and felt totally, perfectly fine after. So--use donation as an excuse to treat yourself to a big meal.

Find a time that works for you. You shouldn't exercise after giving blood, so as an evening exerciser, that used to be a deterrent for me. But by donating at the local blood center, rather than a blood drive, I can schedule a late, 7pm appointment, leaving time to hit the gym after work.

Make it convenient. Here in town, there is a collection center 2 miles from me. And as noted above, it offers a greater time range than the typical on-site blood drive. So that works for me. By the same token, if you don't live near a collection center, then find a blood drive convenient to you. But don't wait for the semi-annual drive at work. Go to the Red Cross or other agency website, and seek one out.

To utterly crush any possibility of inertia setting in, take a page from the dentist. Schedule your next appointment as soon as you have completed your current one. If you are at the collection center, you can probably do it on the spot. If you are donating at a drive, come right home and find the next convenient drive, any time after 8 weeks, and sign up.

PRO TIP: Yes, it involves a needle, and yes, it involves your blood flowing out of your body. That is a little bit quease-inducing and gross. I realize those personally acquainted with me may be thinking, giving may be easy for you, as a strapping exemplar of robust, middle-aged masculinity. Trust me, I am right up there with the corseted 19th-century ladies and their fainting divans, when  it comes to getting easily grossed out. The yech factor in donating blood really is not such a big deal. I have found the best approach is total distraction. I read happily throughout the procedure. Do what works for you--watch video on your phone if that is to your taste.

Speaking of Manning Up on Vasectomies...

(per previous post) In fact, this would have worked very well in the recent Modern Family episode, where Jay takes Phil to get a vasectomy, and Phil is chickening out.

I really didn't like that ending. Phil is waiting in pre-op, having finally ginned up his courage, only for Claire to waltz in and talk him out of it--because she's "not sure" she doesn't want any more children! This is Claire, mother of three, one college-aged, who is herself--how old? In the show, she looks like an extremely attractive 34 or so. But let's do the math. If she were 22 when Haley was born, she'd be at least 40. That's probably the best case, she could be older. Sure, not out of the question for conceiving, but really, she is not in the "just in case we change our mind in a few years" camp. If there were ANY QUESTION of having another baby--which, to be clear, I think is a ridiculous proposition--she should have already been on it.

Then there is the question of Phil's age. He looks even older, pushing 50. Yes, I'm aware that plenty of men don't have children till well into their forties and beyond. But that is usually men who have no kids, or are on their second family. Very few American men of 45 with three kids are raring to have a baby. The reason it usually happens is carelessness! Which brings me full circle...men foolishly avoid vasectomies enough as it is, without any encouragement from pop culture. The show could have handled it so much better.

Decision Fatigue

I am just fascinated by this kind of stuff. Especially the sleep connection. I am a strong believer that adequate sleep is one of the four pillars of good health (along with diet, exercise and healthcare). With sleep, there is a big feedback loop into two of the other pillars. I have seen speculation that a factor in the obesity epidemic is lack of sleep. I connect that to the fact that I read the average adult American--in 1900, before the advent of widespread electric lighting--slept an average of 10 hours in the winter. 10 hours, can you imagine!


It also seems clear to me that there is a connection between feeling rested, and having the drive/willpower to exercise. Unless you are confirmed, "addicted" exerciser, it is hard to drag yourself to the gym, or wherever, and put yourself through the paces, when your brain is whimpering "sleep, rest".

Don't Twist the Facts, Even in Service of Good Policy

The findings from this so-called "pragmatic trial" may change the way British doctors prescribe drugs for the prevention of asthma flares. Patients may be told that it doesn't really matter what controllers you take, although intensive clinical trials suggest otherwise. In effect, the recommendations will be dumbed down, because some (or even most) patients simply aren't very good at following directions. Even savvy patients—the ones who are perfectly able to handle the more complex and better treatments—would be treated the same as everyone else...Should patients be separated by ability groups, as some students are in schools?

I can sympathize with this viewpoint from a pragmatic financial and clinical perspective, but I have a couple of problems with it. One is personal--the dumbed-down, lowest-common-denominator, one-size-fits-all perspective sacrifices too much for those who aren't dumb. For instance, if you don't have high blood pressure and aren't salt sensitive, there may not be much reason to deny yourself the gustatory delight of salt.

The second is more a matter of philosophy, and its long-term implications for public policy. In a nutshell: in the long-run, no good comes from deceit, even deceit borne of the best intentions. People will start to figure it out, sooner or later, and that will breed distrust at best, conspiracy theories at worst.

The Flaws in One-Size-Fits-All Dosing

 It is about time! I have wondered about this topic for decades! This seems so obvious a consideration! Is it due to--for lack of a better term--laziness, on the part of prescribers? Too much trouble to punch some numbers into a calculator, then round to the nearest available dosage?

A subscriber to our Health After 50 newsletter asks: I'm taller and heavier than the average person. Should I be taking a higher dose of antibiotics? ... as an editorial in The Lancet recently pointed out, a 6- foot, 198-pound male with pneumonia will likely be prescribed the same dose of antibiotics as a 5- foot, 123-pound woman. Some research suggests that one-size-fits-all dosing of antibiotics poses a distinct disadvantage for heavier people. Why? Large -- especially obese -- people have comparatively larger blood volumes than their normal-weight counterparts. Consequently, the concentration of an antibiotic in the bloodstream is lower in a large, obese individual than in a smaller one, making it harder for the antibiotic to fight infection. In fact, some experts theorize that insufficient dosing relative to body size may help explain why obese people tend to recover poorly from infections. Insufficient dosing may also push physicians to prescribe more antibiotics for longer durations, thus contributing to the alarming trend of antibiotic resistance. Ideally, antibiotics should be individualized to age, gender and liver and kidney function as well as height and weight. But clinical trials on individualized dosing have yet to be conducted. It's not clear if this would be cost effective, as drug manufacturers would also have to make changes to match individual patients' needs. For now, talk to your doctor about upping your dose if your current one isn't helping

Calories In, Calories Out

A professor ate almost nothing but Twinkies and the like for several months, and wound up losing weight and improving his cholesterol. The key was that he ate a very controlled amount of Twinkies, a lower calorie intake than he had been at previously. This is totally un-surprising to me--calories in, calories out. At least in terms of weight, the total number of calories matters FAR more than the source. This is really basic science and, to me, the fact that so many people are so willing to believe in fad diets[1] is yet another example of the insidious effects of scientific illiteracy.

I tend to think the same way about exercise...for all but the most serious competitive athletes, I think the more calories burned, the better. Little to be gained by worrying about what zone you are in--other than trying to get in the highest zone you can manage, for whatever amount of time you have budgeted to exercise. Though I am somewhat more open to being wrong about this one, because there does seem to be research to support the idea of Fartlek/Interval training's benefits (fitness, more than weight loss, but that's the important thing anyway).

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[1] Actually, you could just about extend this comment to "any diet at all", since the evidence is that yo-yo dieting is worse than never losing the weight in the first place.

Retirement Considered Harmful

I have recently come around to thinking that retirement may not be so healthy, so I found this article interesting:

The two economists call their paper "Mental Retirement," and their argument has intrigued behavioral researchers. Data from the United States, England and 11 other European countries suggest that the earlier people retire, the more quickly their memories decline.

Sweet and Fattening by Any Other Name: High Fructose Corn Syrup

As we all know, high fructose corn syrup is a popular sweetener. I have noticed, over the past few years, that it was being singled out as a major contributor to the obesity epidemic. Without paying a lot of attention, I had my doubts about whether the source of dietary sugar mattered much. Now there are some studies that say it doesn't matter, and the corn people are trying to re-brand their product.

Working at 103

This guy is my hero:

At 103, a Judge Has One Caveat: No Lengthy Trials

By A. G. SULZBERGER

Judge Wesley E. Brown of Federal District Court uses an oxygen tube in his Kansas courtroom but has no plans to stop working.

Fwd: Even More Reasons to Get a Move On

Really good article on the almost endless benefits of exercise. I think maybe the only way to get people's attention is through their wallets. It could be complex, cumbersome and meddlesome, but I think there needs to be a significant premium penalty for not exercising. I think it would have to be at least equivalent to the penalty now assessed to smokers--maybe more. Obviously the upper limit should be the real, actuarial health costs associated with inactivity--if people choose to incur that cost, it is ultimately their free choice.

I say this warily. As a 100 mile/week cyclist, I have my doubts about ever getting credit  for my exercise regime. Hard to monitor, as opposed to the credit for getting through the gym doors 12 times/week.

Heavier Americans Lobby Group

I fall in the middle on this article. Valid point: it certainly not right to disparage people for being fat, and it probably would not be fair or right to penalize someone in terms of heatlhcare premiums solely for being overweight. On the other hand, the likely tendency of this lobby will be to decry any references that cast overweightness[1] in a negative light. And that would definitely be going too far. Because while they are correct in asserting that the real social goal is fitness and health--not thinness thinness' sake--the fact is that overweightness is very strongly correlated with health problems.

Which brings me to my next objection to the article: like almost all articles I read on the subject, it almost completely glosses over the importance of exercise. Yes, there is one nod to the importance of "movement" (movement--talk about euphimisms!), but that's it.

Overlooking exercise is a very unfortunate omission. Because unlike dieting--which is very, very, very hard to sustain because it feels like permanent deprivation--exercise is a positive good. So exercise is far more sustainable than dieting.

In my 20+ years of regular gym attendance, I have very, very rarely seen a confirmed, dedicated exerciser who is severely overweight. Some of us exercise addicts may be bulkier than others, but almost all have weight reasonably under control.

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[1] Using the term "overweightness" rather than, say, "fatness" would be the kind of thing that an interest group might push. I typically detest that sort of euphimism-promulgation by the langage police--detention center for jail, landfill for dump--and would normally resist it. But in this case I think it is justified. "Fat" is a pretty loaded, pejorative term. Likewise for obesity, and anyway, it only properly describes the extreme of fatness. So awkward as it sounds to the ear, "overweightness" seems like the best term available. (Heaviness doesn't really cut it, because it is absolute, not relative--Yao Ming for instance is quite heavy, but hardly fat.)