Bonus episode: in the family // Wednesday, July 22

BONUS: In the Family

Wednesday, July 22

Rerelease for episodes 48: Open for Business & 76: Pandemic Summer

For the next couple of months, Shelter in Place is taking a break from making new episodes so that we can make this work sustainable and bring you season 2. If you’d like to help us with that, you can join our community for as little as $5/month at shelterinplacepodcast.info. You can also sign up for our newsletter, so you’re the first to hear news about season 2 and get a behind the scenes look at our show.

During the break, we’re rereleasing a few episodes from season 1 that we want to make sure you don’t miss. Some of them are episodes we particularly enjoyed putting together, episodes we heard that our listeners loved, too. Others are one that feel particularly relevant to the moment we’re in now.

Today’s bonus episode is a combination of two episodes. What I didn’t tell you in those episodes is that the apple doesn’t fall far from the tree. Dr. Joyce Sanchez, who informed episode 48: Open for Business, is the daughter of Dr. Jose Luis Sanchez, who I spoke with in episode 76. A lot has changed since these episodes were released, but the advice the two Dr. Sanchezes give us is just as relevant now as it was then. I’ll begin with episode 48, which was released in May. 

When we began sheltering in place on March 17, it seemed like finally our world had found something to agree on. COVID-19 was our common enemy. We could band together in a bipartisan way that would benefit all of us.

Nearly eight weeks later, so much has changed. While some of our cities and states are open for business, doing their best to boost the global economy, other places are seeing lockdowns more extreme than ever before. A few weeks ago, there was a certain comfort in knowing that we were in it together. All experiencing some version of the same thing. Now, in some places, wearing a mask has become a political statement. Even in the White House the message isn’t uniform. While our nation’s top health officials warn us that the pandemic is far from contained, our president says “we have met the moment and we have prevailed.” 

Here in the Bay Area, even though California has slowly begun lifting restrictions in some places, trying to keep up with the daily news will give you whiplash. Scanning through the San Francisco Chronicle’s live updates yesterday, there was Elon Musk opening his Tesla factory in Fremont, a spike in COVID-19 deaths in California over the past twenty-four hours, Chinese hackers targeting COVID-19 research. While some countries that had previously opened up are now reimposing lockdowns after a resurgence in COVID-19 deaths, cell phone data shows that millions of Americans are on the move again. 

It’s hard to know what to think. As I’ve tried to navigate the swirl of conflicting news this week, I reached out to someone who isn’t just on the front lines, but who has a better understanding of this disease than most of us.

My sister-in-law Joyce Sanchez is an infectious disease doctor at the Medical College of Wisconsin. She’s been a champion of this podcast from the beginning. She says that listening is the way she decompresses after a long day in the hospital. Which is pretty much what I hope for every time I sit down to write an episode. That each day, my words would be a gift to you, something to help you decompress or just get through another day. 

Still, I’ve tried not to bug Joyce too much during this time, because she’s got a lot on her plate. Not just seeing COVID-19 patients, but helping to educate others about the virus. But this week, I reached out, because I wanted to know what Joyce thought about our current situation. She said, “Most leaders recognize that there are two important things to keep in mind when opening the economy.  The first is that this is not an all or nothing decision. Rather than a “on/off” switch, it is more like a dial that should be adjusted. 

The second is that this is not a one and done decision, but rather a process that includes regular re-evaluation so that the dial can be turned up or down in response to how the pandemic unfolds with time.

Joyce went on to say that the people who are making decisions about this are taking into account both the state of the pandemic in their communities, and the economic effects of sheltering in place.  Considerations are also being made based on whether or not hospitals have adequate PPE, as well as their ability to effectively test for the virus, isolate, and contact trace when there are cases. 

She said, “From a population health standpoint, trends such as number of new cases and deaths are generally tracked. This includes the health of those who are vulnerable (such as the elderly), and communities with significant health disparities (including people of color).”  

The very idea of reopening can create anxiety for those personally affected by COVID-19 through sickness and death, or for those who are vulnerable to the disease.  For others, whose lives have been devastated by the economic impact of shutting down business, reopening is greatly anticipated.  

And yet others live in a state of tension between these two emotions.  When discussing these issues, I try (and many times fail) to remember to listen before I speak, put myself in others’ shoes, and respond with kindness.  For better or worse, how our generation handles this crisis is being broadcasted to the world now and will be recorded for generations to see in the future. To paraphrase Dr. Michael Osterholm, I hope we are empowered to come together in this, not apart.”

As someone who is living in that tension that Joyce mentioned, I take a lot of comfort in her words. Our family has lost our source of income because of COVID-19. The past two months have brought upheaval we never could have imagined or anticipated. But we’re also feeling nervous about rushing back to business as usual. We began this time of sheltering in place worrying that both Joyce and some close friends here in Oakland had the virus, which I shared about in episodes 3 and 4. There is no price or paycheck worth it to me to lose the people I love in this world. Our world has already lost so many.

I’ve been thinking lately about the phrase, “my right to swing my fist ends where your nose begins.” Variations of that phrase have been attributed to Oliver Wendell Holmes, Jr., John Stuart Mill, and Abraham Lincoln. It turns out that we don’t know the phrase’s true origins. The closest I got was a 1857 excerpt from the Salem Register, where Leon Chautard, a Frenchman who had escaped from being imprisoned by Louis Napoleon for his political opinions, said; 

“My home is my castle,” says a free citizen.—According to the laws of men, this may be right. According to the laws of nature, this is often wrong. If you are about to kill somebody in your home or set it on fire, and I break open your door or your window, I enter your castle, I prevent you from killing or setting fire, every one will confess that I am a good citizen; I have saved a person from death or a town from incendiarism. No law can punish me for that.

Consequently your liberty ends where the liberty of others commences. Consequently every one has a right,—more than a right, a duty,—to prevent what may hurt others’ interests, persons or property.”

This particular excerpt was talking about slavery, but it feels eerily appropriate to the times we’re living in now. My home is my castle, though, in my case, it’s a rather small one. And my liberty to move about and risk my own health ends where it bumps into the liberties of the people around me. 

It occurred to me this week that maybe the reason I’m not rushing to get back to pre-COVID-19 living is that I know in a bone-deep way that my actions do affect others.

Living in the Bay Area, where our small houses are close together and our yards--if we have them--are often smaller, we’ve been trained for social distancing. On any given day right now, I can sit in my backyard and hear one neighbor on a Zoom call for work, while another tends his garden. I can hear the chatter from dog walkers saying hello to each other from across the street. Last night at three a.m. I woke up to the sound of another neighbor’s baby crying. For years we’ve had to impose curfews on when our kids are allowed to step outside the house, because their tantrums or even talking will disturb our neighbors if it’s too early or too late. On the days when my next door neighbor’s yard guys come, I often have to wait until evening to record, because the sound of leaf blowers and lawn mowers is constant. 

I know to some of my friends and family, who prefer being out in the country, this description of my life sounds a little claustrophobic. Sometimes it is. But it’s also deeply comforting to live in this kind of community. Those times of my kids tantruming on the back porch have opened up opportunities for sharing parenting struggles with the people who live around me. It’s meant that over time, my neighbors aren’t just neighbors, but friends. We’re a neighborhood that bumps into each other sometimes, but we take care of each other, too. That has never been more true than right now, during this time of sheltering in place.

I wonder if I would feel very differently about this pandemic if I lived on acres of land, or even in a place with a yard big enough to not worry what my neighbors might see or hear. If I could swing my arms and not worry about hitting someone else’s nose, maybe all of these efforts to flatten the curve would feel a little excessive. But for those of us who have long been used to keeping our arms close to our sides, doing our best to smooth over the times when we accidentally bump the noses of others--which, we inevitably do--the need to take prevention measures still feels very urgent and present. 

When I walk around my neighborhood right now, I see a lot of masks. People are still nervous. But they’re not unkind. Even with masks, you can see people smiling. There’s a sense of camaraderie. Of supporting each other in a new way, until we’re sure we don’t need to anymore.

I’m guessing it’ll be a long time before that changes, maybe months or even years. As I try to make decisions for my own family I’m trying, like Joyce, to listen before I speak. To put myself in other people's shoes and respond with kindness. To see if even now, whether we’re turning the dial up or down, we can come together in this, not apart. 

I’ll be right back with my conversation with Dr. Jose Luis Sanchez right after this.

Laura: We’re several weeks into the summer, and I have to say that I had really hoped by now that life would feel a little more predictable, that COVID-19 would have faded into the background for a few months while the weather was warm. But of course that hasn’t happened. The number of COVID-19 deaths in the US alone is approaching 120,000 and we’re starting to see resurgences in places like Florida where things have opened up. It doesn’t feel any easier to make plans for the future than it did a couple of months ago. So on today’s episode, I’m talking with someone who can help us navigate this pandemic summer.

Episode 76: Pandemic Summer 

Jose: My name is Jose Luis Sanchez. So the name is Sanchez. The game is preventive medicine. I am a public health preventive medicine specialist who has specialized in infectious disease epidemiology while working with the U.S. military for 41 years of my life. In my position as Deputy Chief of the Armed Forces Health Surveillance Division, I look at policy issues for the DOD (for the Department of Defense), looking at diseases and injuries.

I am originally from the great state--soon to be state, maybe--territory so far--of Puerto Rico. And I am very glad to be here today with you talking about COVID-19, better known as the coronavirus  two. 

Laura: Before we continue, I need to give the disclaimer that Jose is not representing the Department of Defense or the US military establishment. I’ve put a full disclaimer in the show notes for today, but it’s important to note that the opinions you hear in this interview are Jose’s alone. 

Since Mid-March, Jose has been working almost exclusively on COVID-19. So I took this opportunity to ask him all of the things I’d been wondering over the course of this pandemic. I’ve read the CDC guidelines, but I wanted to know how an expert was navigating this time for himself.

Jose: Regardless of the phase a particular state or county is in, I think we have to get used to a new normal. And that new normal is when we go outside of our homes, we need to make sure that we are wearing cloth face masks or coverings. We need to make sure that we observe social distancing, especially when in crowded locations. And we need to get used to increased personal hygiene sanitation, frequently washing our hands with soap and water. And when we travel, try to travel in small groups, preferably by car instead of by plane, so that you can  have control over the extent of possible exposure.

We should make it a habit from now on until this virus comes under control. And I feel it will not come under control--it will continue to surge in spikes--until we have a national vaccination program, which we will not have before the spring of next year. So we're talking about a period of at least nine, maybe 12 months, until we can relax these measures. 

Laura: Do you find it concerning that in a lot of places in the country, people have kind of just gone back to the way things were before? And do you think we'll see a spike because of that?

Jose: Not only do I think we'll see a spike, but like Dr. Anthony Tony Fauci has stated, we will continue to see spikes in different locations where individuals are beginning to engage in crowding conditions, where they're gonna significantly increase their risk of acquiring this virus.  So we will continue to see spikes. I am very worried about that. 

This virus is not going to go away, I believe, this virus is going to become endemic. That means it's going to become a natural part of our environment. It’s going to be carried by people for a long, long time, probably for years, even in the presence of a vaccination, because no vaccine is a hundred percent efficacious.

One of the reasons I believe this virus will become endemic and cease becoming an epidemic year in and year out, (is) because I think we will reach a level of herd immunity. When I talk about herd immunity, what I'm talking about is having individuals having sufficiently immune antibodies, and immunity to the virus to the level that we get 60 to 80% of the population becoming immune to this virus. And once we reach that, we will see cases happening, but in very few numbers, and this is based on experience with other viruses where the same thing has happened, such as with influenza viruses of different kinds. The last pandemic we experienced was that Influenza A H1N1 Swine Flu pandemic. And that virus is still circulating, but in low numbers throughout the world, but the population has reached such a level of immunity that it's now not a pandemic anymore. It ceased being a pandemic in August of 2010. I do believe based on that and other of viruses that have caused epidemics and some (that) have caused pandemics, that they would become endemic in the population and the herd immunity is sufficiently high--that plus the vaccination efforts--I really do believe there will be if not one, several vaccines that will be administered nationwide and in other countries by the spring of next year.

There is a huge effort, not just in the part of the U.S. government, but other governments. There are about 160 different vaccine constructs that are being looked at, and of those there appeared to be three or four right now that are being heavily invested upon by the U.S. government for their development and final use as a universal--some type of a universal vaccination program, hopefully by the beginning of 2021. I don't think we'll see them become a reality until maybe February or March of next year.

Laura: On the subject of herd immunity, for people who say, why not just let COVID-19 run rampant and then we all get herd immunity?” What do you say to that kind of thinking? 

Jose: The answer is simple. I think it’s ludicrous to think that we should let people get infected, because as we have seen so far, there've been at least 120,000 deaths in the United States alone. I don't think you can talk to families and people that have seen loved ones die from this virus and convince them (to) let nature take its course. 

Now, I think we should continue to practice the new normal. And then we will have to reevaluate once a vaccine or vaccines come into play, depending on the results of those vaccination programs, whether we relax those measures or not. So it's a new normal, we need to get used to it. I disagree with those that think that we should just let nature take its course and relax, because people are going to die and people are going to die in big numbers.

The latest predictions are that we may see before the fall this year, as many as 200,000 deaths in the United States. That's within a period of six months. That's three times as many deaths as we see with a bad flu virus. With a bad flu virus you see about 60-70,000 deaths in the United States.

Laura: What do we know at this point about how the virus actually spreads? 

Jose: This is a virus that spreads by close proximity through airborne droplet transmission, principally, but not exclusively. You have heard about the six feet rule. That's your main source of risk, but it can also be transmitted by fomites. That means by people touching contaminated surfaces and then putting their hands in their mouth or their nose or their eyes, and we also know that the virus lasts for at least a few hours and sometimes a couple of days on different types of surfaces. So even when you are covering yourself and avoiding being in close contact with others, you have to be careful about the surfaces that you touch. 

The other ways that are being examined that potentially could become important is the fecal oral route from aerosolization of feces as happens when you're flushing toilets. We know that the virus can be found in blood for a very limited amount of time, and it can be found in saliva. I would not be surprised at all if in the near future we find transformation via the sexual route because the virus can find its way  into seminal fluid. I would like to see more data before I discard the possibility that that could be a mode of transmission. 

Laura: Alameda County, the county that I live in, just mandated that even for people exercising, like going for a bike ride or a run, you have to wear a mask. And I've wondered, is that a little extreme? Because you know, if I'm passing somebody on my bike, I'm passing them for, like, two seconds. I'm more than six feet away from them. Or even if I'm not, it's so quick that I'm passing by. Am I being too cavalier about it, to think that that's a little extreme? 

Jose: So I am of the opinion that you are not being cavalier. I share your opinion that if you're in an open space, whether you’re running or trotting--because I cannot run anymore. I barely trot. But I never wear a mask when I'm trotting, because when I encounter somebody I'm not blind, so I can see people that are coming towards me. Sometimes I miss the ones that are coming behind me, because of course they're running faster than I am. Not much I can do about that, ‘cause I'm old. But having said that, I think you do not need to wear a face mask or a cloth face covering if you are running out in the open, or if you're biking out in the open, because the dissemination of the virus and the dilution of the virus--the potential for you acquiring or actually infecting somebody that you encounter on a running trail, it's negligible. And I will extend that not just to biking and running, but also when you're in your car, when your windows are down, so that you're diluting any potential virus that you're putting out into the air. If you are driving with your closed windows, then as long as you're within your family group (with the people that live with you day in and day out), then you don't need to wear a mask either. But if there is somebody that gets into the car, then you should wear a mask, and that person should wear a mask. 

Laura: And what about for people who are feeling freaked out about getting the virus from their groceries, say? I mean, is that a legitimate concern? 

Jose: That is a legitimate concern and it's very simply taken care of by you ensuring that after you put that fruit or that item and bring it home, the first thing you do upon entering your home is washing it well with a hypochlorite solution or with just soap and water, and then washing your hands with soap and water. So you gotta make sure that those food items are clean, and you gotta make sure that your hands are clean.

Laura: The first week of this podcast I shared that my friend Annie was being tested for COVID-19. Her test came back negative, but the doctor who read her chest X-rays thought she was a false-negative. A few weeks later she took an of the antibody serum. Which also came up negative. I asked Jose about both the antibody serum and the COVID-19 tests, to try to get a sense for how reliable these things were in detecting the virus.

Jose: In terms of the detection of the virus itself--not the antibody, but the virus now--the tests are pretty good. But the problem is that in many cases there's not enough viral load in the respiratory tract, or when the sample was taken maybe you're taking the sample too early in the course of the illness of the individual, so that it's negative, when actually the individual is infected. When you're talking about RTPCR, you're talking over 95% sensitivity and our 98% specificity. 

Laura: In other words, if you get tested for COVID-19 when the viral load is high enough, the tests are pretty accurate. But Jose says that the antibody serums still have a long way to go. At best, they’re 60-80% accurate.

Jose: There is good data to show that those that are 19 years of age or less are less susceptible to infection than adults that are 20 years of age or older. There's nothing magic about the 20 year old barrier, okay? It’s gradual. And that has to do with the fact that there's increased susceptibility to infection or serious illness among children that probably results from cross-immunity from other coronaviruses, or it could be because they have anatomically less capability to be able to acquire the infection. They're also at a lower risk of serious complications if infected. So I think in terms of their very young children that go to daycare, there are ways that you can limit transmission in those settings. I don't think those should be shut down either, much like I don't think schools should be shut down. 

Laura: Our schools open up in August. We still don't know what that's going to look like. They're talking about smaller class sizes, maybe only just a couple of days a week.

Jose: I think schools should reopen in the fall offering as many options as possible for Internet or web-based education. Schools are needed, but there should be social distancing and personal hygiene rules that will minimize the risk of infection. We will not be able to stop it completely, but minimized transmission in a school setting is possible. 

Laura: Here we are in June. It feels really, really hard to make any decisions about anything right now, like my parents are asking me, are you going to come to the Midwest this summer? Are you going to get an airplane at the end of July?

Jose: My answer is a straightforward no. I'm sorry.

Tell your parents and your family and relatives that because of the ongoing threat of transmission and acquisition of the virus, I really think it's still a high enough threat to warrant being conservative. That's part of the new normal, I think. 

Laura: COVID-19 has affected different populations differently. What are your thoughts on why Black and brown populations are being hit so much harder than white populations?

Jose: So there's a combination of factors that come into play. First of all, Black and brown populations are, in general, a lower socioeconomic status. Now, that varies between cities and regions around the country, but in general, that is true. 

Number two, there are many brown and Black populations that do not have ready access to healthcare as much as white populations do in the United States, and that's well documented. 

And third--and probably more important than the previous two reasons--conditions that lead you to be at increased risk of infection or suffering from severe diseases such as diabetes and cardiovascular disease and hypertension and obesity are much more prevalent in Brown and Black populations than they are in white populations. There needs to be a widespread commitment from public health authorities and political leadership towards increasing knowledge and access to better nutrition for these populations, so as to avoid conditions such as obesity or diabetes, for example. 

And last but not least, probably more important at all, is making sure that we can extend access to work so that these populations stand a better chance  to confront the pandemic. Because everything revolves  around the economy, really, when all is said and done. And if you don't have money to pay insurance, you are at a distinct disadvantage, and you are at a distinct increased risk of suffering from severe COVID-19 when and if you are infected. It’s as simple as that. 

It's inequity that we see in society. I am not a politician, but I do believe there needs to be a national healthcare act that ensures ready access to medical care for all. I know that it's a politically, a hot potato. But it's paramount for us to find ways in which people that don't have access to care get access to care. There needs to be something akin to the social security act--there needs to be a health care act that ensures universal access to health care, much like we do in the military.

I don't know if you realize that the military is one of the few populations in the United States that gets universal access to healthcare. We have almost 10 million active duty and beneficiaries that get taken care of by the military health system every year.

Whether you're having a cold, or whether you're pregnant and having a baby, or whether you need some major surgery for some major condition, or you need emergency care, it's accessible and it's free of charge to members of the military and their dependents and family. 

The political will for our leaders to take action, much like they’re taking action now in terms of police brutality and enacting laws towards mitigating that problem, they should take action now to make sure that there's equal access to care by all in the United States by all populations. We need to make sure that we talk to our political leaders, and make sure that they understand that it is extremely important for them to enact laws that allow universal access to healthcare so that individuals that are at risk can be taken care of, not just for the sake of COVID-19, (but) for the sake of so many other conditions that tend to be more prevalent and lead to serious complications and death and higher mortality in disadvantage populations that don't have access to healthcare.

Laura: I’m slowly adjusting to the idea that we’re going to be in this new normal for a while. Much as I would like my kids to go back to school, I also recognize that the challenges of that situation are complicated. My neighbors and I are talking distance learning co-ops and family pods. We’re trying to figure out how to make Shelter in Place a sustainable business while we try to figure out family rhythms that will help us, too. 

I’ve come to realize during this time that sheltering in place isn’t just about quarantine. It’s about community. Whether our shelter feels like a cage or a sanctuary has a lot to do with the small choices we make every day, the things we choose to put our hope in, the people we reach out to. So the daily sanity today is to accept the new normal--but to resist the urge to feel defeated because of it.