Category: Reflections on Life, Being Human, and Medicine

When I was in 7^th grade one day, Mr. Houseman, our science teacher, gave us a math problem. 

He told us the story of the miser and the blacksmith.

A blacksmith is putting shoes on a miser’s horse. The blacksmith charges $10 for the job. The miser refuses to pay. “Ok,” the blacksmith says, “I will make a deal with you. There are 8 nails in each horseshoe.  The horse has four shoes. That would be 32 nails in all. I will ask you to pay one penny for the first nail, two pennies for the next nail, four pennies for the next nail, eight pennies for the next nail, etc… until the 32^nd nail.”

Our teacher asked us if we would take the deal if we were the miser. Most of us said, “yes.”  I mean – it is just pennies. It won’t add up to very much.

He then had us start doing the math and told us to bring our answers to class the next day.  We were told that we had to do the math by hand (no calculator) and that we had to show our work.

If any of you have ever done this problem, you know the secret. 

Later that night at home I had a huge piece of paper filled with numbers. With each additional nail the numbers got bigger and bigger. It was hard to keep it straight and to do the math by hand.

The total cost was $42,949,672.95 (almost 43 million dollars).^[1]

What is the trick? It has to do with exponential growth. If you want to see more interesting illustrations, search for exponential growth on YouTube.^[2][3] What you will see will be a variety of similar illustrations. They are really quite wild. 

It doesn’t make sense. It defies common sense.

But it is real.

Why does this matter and what does it have to do with COVID 19?

COVID 19 in a society without suppression has an Ro or rate of spread of 2. This means that it follows the same math as the miser and the blacksmith problem.  That means that how it spreads will not make sense from a gut level or common-sense approach. That math however can be alarming.  If it were to spread unchecked, it can seem like nothing is happening and then seemingly out of nowhere – a simple $10 job becomes $43 million. Or a few cases become tens of thousands and hospitals and health systems become overwhelmed.

But if suppression measures are done and are effective, the Ro can go down and the exponential growth goes away or is reduced.

In early to mid-March, our health system and the experts they relied on started using epidemiologic mathematical methods to predict what might happen.  The graphs and predictions were terrifying. We were looking at needing thousands and thousands of hospital beds, intensive care rooms and ventilators. The potential was far greater than any health system could ever handle. 

The next models looked at what would happen if we implemented social distancing. They started out estimating based on a 30% social distancing model. This assumes that we can never completely 100% isolate everyone from everyone else. If you have to pick a number what number is realistic? Experts suggested that the reasonable degree of social distancing that we could expect in our population would be around 30%. 

The models started giving us data that we could potentially work with. The demand still looked enormous, but it was at least in the ballpark.  The predictions included a peak of 2500+ patients in the hospital with 1000 patients in the ICU and around 700 on ventilators at a time.  It meant that we would exceed all possible capacity of the hospital system. Teams went to work implementing plans to build out more and more capacity depending on what happened. 

Something different happened in West Michigan, however. Cell phone data has suggested that the degree of social distancing has in reality been around 58%. This has had a dramatic difference on what has happened. Instead of the huge surge in numbers of patients with COVID 19, it has been a steady stream of patients with numbers in the range of 50-80 patients per day in the hospital.

Does this mean that the models were wrong?

The answer lies with the miser and the blacksmith. 

It has to do with exponential growth. If we achieve a high degree of social distancing the exponent drops. Depending on the exponent, wide variations in the numbers of cases at a time can occur. The math shows that what happens can go beyond what common sense will tell us. 

The projections depend very much on the percent of social distancing that is achieved. If it loosens up a small amount (which seems likely based on the trends in society) then the numbers look like there will be a higher peak (perhaps around 500 patients per day in the hospital).  

Is this all theoretical? Nope.

It suddenly makes sense of why we can have had such dramatically different outcomes in places like New York City or Detroit compared to Grand Rapids. Those places that had time to implement social distancing before the exponential growth took off have a lot lower numbers of cases.  The experiences in the US (and the world) match the math.

So – we might only see about 50-100 patients in our hospital system at a time (the current state), or we might peak at 500 (if social distancing loosens a little bit), or we might have 2000 (if restrictions are loosened a lot.)  

But then where do we go from here?

As I stated in a prior blog^[4], the problem is not with the math or the effectiveness of social distancing. It has all worked. 

The problem now has to do with sustainability.  The tail end of the curves are now extending far into 2021. We are all going to be forced to figure out different solutions on how we can live through this. We need to somehow maintain some degree of safe social distancing – but we have to be able to do it for a lot longer than any of us would like.

In some ways it is like trying to open the valve on a fire hose just a tiny amount so that you can get a drink. We are very thirsty. Not opening the valve is not really an option. Maybe we will be good enough to open it up a little bit. Maybe we won’t and we will get blasted in the face. Maybe the number of cases will go up a modest and manageable amount. Maybe the number of cases will surge and we will see repeats of New York City and Detroit.

A Wall Street Journal headline yesterday described May 2020 as being one of the greatest social experiments in history.^[5] The huge experiments are going on in states that have loosened up social distancing (like Georgia and Texas.) I am really hoping and praying that these go well. If they do perhaps they can provide lessons and a guide for all of the rest of us. 

I don’t have the answers. 

But I did find it very interesting to look at YouTube posts from 2019, 2016, and 2013 that described potential pandemics and the exponential math that has happened in our world.

The miser and the blacksmith and what I thought was an odd assignment from Mr. Houseman comes back to me so many years later.  It makes so much sense to me for what is happening in our world now. Who would have thought it?

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^[1] https://www.pedagonet.com/brain/brain43.htm

^[2] https://www.youtube.com/watch?v=Tm38xA3KcQY

^[3] https://www.youtube.com/watch?v=0BSaMH4hINY

^[4] https://manmedicineandmike.com/the-path-forward/

^[5] https://www.wsj.com/articles/america-wants-to-reopen-from-coronavirus-but-disagrees-about-how-11588350721

My wife has a good sense of direction. She loves to look at maps and help us figure out the best way to get places. When we travel, she usually navigates, and I drive. 

We were driving to stay at an inn. As we got close I began asking, “Is this the place? Is that the place? What drive do I turn into? Is it this drive? Is it the next one?” Because she is navigating for some reason I expect her to know exactly what everything will look like.

She answered (like she has many times in the past), “Honestly – I don’t know. Neither of us have ever been here before!”

I am now asking myself and being asked by others what I think during the current COVID 19 crisis. What is really going to happen?  How many are going to die? What is this going to look like in West Michigan? Is it really going to get bad here? I find myself saying the same thing, “Honestly – I don’t know. Neither of us have ever been here before!”

We are moving through stages. I know where we have been. I have a good idea of where we are now. But to be honest – I don’t know – nor does anyone really know exactly where we are going. We are relying on our navigators, but even they have never been here before:

• Stage 1: Denial – It was just going to be another one of those China things.
• Stage 2: Wishing – Well, maybe it will be contained and just be sort of a west coast thing.
• Stage 3: Unsettled – Crisis decision making, dramatic changes in life and schedules, constant meetings trying to figure out new things, odd quiet settling over the hospital and day by day things being taken away from my life.
• Stage 4: Preparing for battle – Taking on new challenges. Setting up an improvised home office. Doing my first days of “seeing” patients via video visits and telephone visits. Constant Microsoft Teams meetings. Zoom get togethers to counter the isolation. “Surge” or as I would think about them “doomsday” planning meetings. Hearing horror stories from New York and then Detroit. Bracing myself for the sudden impact of a COVID 19 surge. It was supposed to be here in a week or maybe two or was it three?
• Stage 4 (now): The “Turtle’s Back” – Someone used this analogy and I think it is interesting. Social distancing has worked in West Michigan. The curve has flattened and continues to flatten even more. The modeling still says that we will get a “surge” but now it is getting pushed further out. When it hits it is supposed to be of lower intensity and longer duration. It is no longer a big spike and then drop. Rather than a tidal wave, it may be more of a very large swell that goes over our heads and stays there. We will be treading water and may have to do so for longer than we like. But hopefully we are now strong enough and prepared enough to keep our heads above water until the swell goes away.

It is now like the shape of a turtle’s shell (viewed from the side). We will have an increase and then a sustained high level of cases and then eventually a decline. They are still predicting that it will exceed all standard healthcare capacity. Fortunately, we have had time to prepare and with the flattened curve it will be more manageable. This is wonderful news. And this is terrible news.

It is wonderful that we should be better able to manage it. But the flat curve keeps extending further and further out. This means that this whole thing is going to go on a lot longer than people understand. I am afraid to even write about how long this may go on. But trust me – it is longer than you want.

What does this all mean? 

Two weeks ago, I was in an electronic meeting. I looked at the updated projections for West Michigan. I saw my Michigan summer slipping away. I came downstairs from my home office and sat in the living room with Sarah and felt incredible anxiety inside. I started to doubt if our society really could – or would – sustain this degree of social distancing for as long as we need them to.

The word that came to my mind was “sustainability.” 

We have all been running a sprint. It looks like we need to shift to running a marathon. 

We did this at work. When this started, in the hospital and our medical practice, we rapidly were cancelling things – patient appointments, procedures, etc… Slash, slash, slash. We were putting things off for a few weeks – then maybe 6-8 weeks. That seemed right at the time. It isn’t anymore.

In our lives we were doing the same thing. We locked ourselves inside and hunkered down like we would have for a couple of snow days. Now that it has been a few weeks – that strategy is feeling bankrupt.

Sustainability.  

How can we sustain social distancing for the long hall?

As a society? As an economy? As a business? As a family? As a human being?

We need to start asking strategic and hard questions. 

There are a lot of people that want to jump to either stage 1 (denial) or stage 2 (wishing that this is just a Detroit thing) again.  

The fact that they haven’t seen the horror of COVID 19 themselves makes them want to go back to my stage 1 or my stage 2. They want to say that it isn’t as bad as we were told. There are plenty of posts about embracing “herd immunity.” Just get it over and done with. Can’t we just pass through this like we do with influenza every year?  Can’t we just take our lumps and be done? Aren’t we doing equally as much harm with the economic and social destruction of social distancing? 

It is only rational and normal to ask these questions. I see people getting angry and divided over this. We have to ask all these types of questions if we are going to figure our way through this.

I don’t think abandoning social distancing and embracing herd immunity is the right strategy. Let me explain why.

1. There is no denying that this is a bad virus and a bad disease.  We have read the stories. People get really sick.  Even those who do not get hospitalized can go through being scary kind of sick. A lot do get hospitalized. While not everyone gets that sick, a lot of people do. In healthcare we see a lot of different illnesses. This is different. It is not business as usual. It is real. It is scary.
2. There is no question that this can spread so quickly that it can exceed healthcare resources. We have heard about “Ro” and exponential growth. These are not just theoretical concepts. Italy, New York, and Detroit are just 3 strong validations of what can happen with rapid spread. We may not have seen it in West Michigan, but experts really think it is because we were 2 weeks ahead of Detroit in our social distancing. They got hit by a tidal wave with their back turned. We looked and locked down and didn’t get hit.

This disease is bad. It is not speculation. It is not hype. It has happened, with devastating consequences not once but in multiple locations. When healthcare resources are exceeded, then the case fatality rate starts to climb dramatically. 

Will it happen in West Michigan? I don’t know. I hope it doesn’t.

But, I for one expect to have medical care if I need it. 

I have thought about what I will do if I get COVID 19. I will try to tough it out at home. Sarah and I have talked about how we will distance from each other but closely monitor each other if one of us gets ill. And if I get ill – really ill – I expect that there will be a hospital bed, oxygen, someone to monitor me and someone to “prone me”. If I really need it – I expect that there would be a ventilator for me. I would consider it unacceptable if the numbers are so great that I will just be left to fend for myself.

That is why we have done all of this. 

We have done it so that we don’t have to have an eye doctor or an inexperienced medical student trying to run my ventilator. We have done it so we won’t get put on a makeshift cot in the hospital cafeteria or in a convention center hoping for the best. We have done it so that there is a state of the art ventilator available for me if or when I need it. 

But what we are doing right now is not the answer either.  

We need to shift and figure out how to make this sustainable. What things can we do to protect those who do need to work? Frankly I am bothered about the safety of the workers who have to stock the shelves for me. I am bothered by the people who cannot work electronically from home who now have no income. I am bothered by the growing wave of unrest as people struggle to adhere to strict stay at home rules. What can we do to allow more people to work? What parts of our society can we get moving again? Can we learn – and change – and do things smarter – better – safer?  Can we do them for the long haul? How can we survive all of this?

We need to have asked the question: “How can we maximally socially distance and do it in a way that we can sustain it for 4 months or longer?” 

There are two competing messages at the moment. One message is that we must keep it all up and do it even more tightly. Our governor surprised a lot of people when she tightened rather than loosened the restrictions in the state of Michigan. She is hearing the reports from Detroit. She is hearing the cries of healthcare institutions and workers begging for relief. She is hearing of violations of social distancing and experts begging for her to fix it. 

But there is another very valid message.  Let me lay that one out below:

1. Thank you! So many of you have done an amazing job. I have seen the empty roads. I have seen the empty stores and people standing 6 feet apart. I have seen people volunteering to make masks and asking what they can donate. I have seen churches close their doors and remake themselves in new and creative ways that they never dreamed of. I have seen grandparents wave out the window with arms that ache to hold their little grandbabies but staying apart anyhow. I have seen high school seniors give up those most important final few months of their high school life.  Thank you!
2. You have made a huge difference! Our case rates for COVID 19 have remarkably flattened and remained low. Your behavior has changed what was thought to be inevitable. 
3. I am sorry for your losses. The trauma of this has been more than just illness and deaths. The lost jobs and lost income and economic losses are not just about comfort. These are real and meaningful and painful. I know it. I am sorry.
4. Six months is different than six weeks. We need a long-term strategy. We cannot just shut down the world and do nothing. We cannot expect everyone to just stay locked in their homes. We need businesses to manufacture and people to work. We need to think about how to create a “new normal” where we can prevent the spread, keep the curve flat and yet not destroy our society.

There are very strong opinions about the protest in Lansing this week. I am not here to defend or criticize that. I am only here to say that what drove that protest is a cry for help. It is a cry for answers about how we can go forward if COVID 19 is truly going to be a problem for many months. It was anger that we did not hear about the 4 points described above.

What is the path forward?

What is really going to happen?

Honestly – I don’t know. Neither of us have ever been here before. 

But we are going to need to do the best we can to figure this out. We need open dialogue and smart people to re-engineer society. We cannot just judge or yell at each other. We are on the same team and fighting the same enemy. From what I can see now, this is:

• Real. There are people getting really sick and places where healthcare resources are overwhelmed.
• Not going to be over as quickly as you or I would like.

We have some more work to do.  

Yesterday 6 Midwest states (Michigan, Wisconsin, Indiana, Kentucky, Minnesota, and Ohio) announced their plans to work together to figure out how to safely reopen parts of our society. I have seen incredible ingenuity, energy and creativity over the past several weeks. Things that were in the past not possible have become possible. The people in our health system have been amazing. Many of you have been amazing. Can we as a society figure this all out together – responsibly – practically? 

I know we can. We must. We will.