The Flu Shot Lowers Stroke Risk. It’s Time to Schedule Yours.

Fall is just around the corner and its time to start scheduling your flu shot. This season we have the high dose quadrivalent vaccine for people 65 years of age or older and the Quadrivalent for those younger than 65 years of age. The vaccine takes about two weeks to provide full immunity and will reduce your chance of catching the illness.  Most importantly, it will prevent serious illness requiring hospitalization and or death. Last year influenza caused almost 45,000 deaths in the USA.

The vaccine is being given in our office. My patients should call 561.368.0191 to schedule the flu shot. You can take this vaccine at the same time as the new Omicron specific booster and near that vaccine which is being given at local pharmacies including CVS and Walgreens.

The journal Neurology published a peer reviewed article that examined whether getting a flu shot provided any additional protection beyond preventing the flu  The study, led by Francisco Jose de Abajo, MD, MPH, PhD of the University of Alcala in Madrid Spain, showed that the flu vaccine reduced the risk of stroke by 12% in those who had risk factors for cerebrovascular or cardiovascular disease. The study noted the protection began within two weeks of receiving the vaccine for both patients with cerebrovascular risk factors regardless of age.

Another study published several weeks ago noted that the risk of dementia was diminished in those patients receiving the flu shot as well.

Flu season is here. Please call the office and schedule your vaccine.

Bisphosphonates, Prolia & Forteo in Osteoporosis Treatment

When I started practicing clinical medicine in South Florida there were few if any treatments for osteoporosis. We saw the devastating effects of this condition in lean post-menopausal women in their seventies and eighties – especially those who had multiple pregnancies and smoked. In men we were more likely to see it in male smokers taking corticosteroids for an inflammatory disease.

Spontaneous collapse of their vertebrae leading to nerve compressions, brutal unrelenting pain and at times neuromuscular injuries preventing walking were common. If we measured height, we saw a decrease in height over time before these catastrophic spinal injuries occurred. We also saw a plethora of spontaneous hip fractures which occurred causing a fall with trauma. In most cases, both presentations resulted in major and extensive surgery and rehabilitation before a patient resumed their life. The only medications we had at the time for women were estrogen and progesterone which carried their own list of potential adverse effects.

The introduction of oral bisphosphonates changed that. Medications like Fosamax, Actonel, Boniva slowed down the process and, with weight bearing exercise, smoking cessation, appropriate nutrition, and luck, reversed it. These medications in pill form were tough to take and still are. They are large, poorly absorbable and require you to take them on an empty stomach while upright. Most instructions call for drinking eight ounces of water with the pill followed by another eight ounces of water after the pill then staying upright for 30-60 minutes. These pills are extremely corrosive if they get caught in your esophagus because you didn’t swallow them with water. They can upset the gastric lining of your stomach as well.

Bone Densitometry tests allowed physicians to detect and then follow serially over years the thickness of your bones. I believe due to the size of the pills and the gastrointestinal problems they can cause convincing patients to try these medications has always been a difficult prospect. Fortunately, much of the responsibility falls on the gynecologists who look for osteoporosis and osteopenia as part of their evaluation of perimenopausal women routinely.

For those individuals unable to tolerate these oral medications, or unwilling to try, rheumatologists have injectables to help the bones. Prolia (denosumab) an injectable given every six months, and Forteo, (teriparatide) a daily injectable, were developed. They too can produce side effects including back and bone pain and a host of others. The good news is they work.

In a recent study of 50,862 women published in the journal Therapeutic Advances in Musculoskeletal Diseases researchers from the University of Verona, Italy led by Giovanni Adami, found that the oral medications can reduce the risk of fracture by 30% while monthly Prolia did so by 60% and daily Forteo by 90%. The significant difference was the fact that the oral agents required one year of use before the risk of a spontaneous fracture occurred while the injectables achieved success much sooner. While rheumatologists and gynecologists surmised this was occurring, this study provides solid evidence to back up their hunches.

Cancer Detection Blood Test – Pros and Cons

For several years I have been following the development of blood tests drawn in a physician’s office which can be used to detect malignancies in their early stages. Recently, a publication discussed the proper use of four blood tests that already exist paired with a flow sheet or algorithm to identify those individuals most likely to develop pancreatic cancer. I am in the process of researching that study and learning how to introduce it into our office practice for my patients benefit.

Two weeks ago,  a wise, worldly, extremely disciplined, and health-conscious individual asked me if I would draw blood on him and send it to a particular lab for evaluation and detection of early cancers. I had not yet received any literature on this company or test, but it is certainly easy enough to draw blood and send it off. He provided the name of the firm and through the miracle of computers and the internet I found their website and information about the testing. This firm was in the fifth year and version of cancer detection.

They have learned that developing malignancies send out a signal through the bloodstream using genetic tools to announce their presence. Their genetic methylation testing procedures can detect these early signals. The company went on to say that for many cancers such as breast cancer, lung cancer, prostate cancer, colon cancer and skin cancers there are quality driven early detection screening programs available to patients and physicians. About two thirds of cancer deaths yearly occur in cancers with no early detection programs designed to find them. Their blood test was designed to do just that. The website for the company listed their research findings, the endorsement of several major national cancer centers in the United States and contained an educational video for doctors and patients.

It was clear from the video that if my patient were to receive this test, I would be a passive phlebotomist drawing her blood and sending it to the lab. I first was asked to establish an account and agree to receive the results and explain them to the patient. Thus, my role was no longer that of a passive good Samaritan. I was expected to be an interpreter of an innovative technology I knew little about.

The cost of the test was listed as $1250 but my patient assured me, she could get it for less at $955. The turnaround time from drawing the blood, to receiving results, is supposed to be less than two weeks. I called the Center for Medicare Services (CMS) and Florida Blue Cross Blue Shield and asked if this test would be a covered service. They both said it would not. I next asked this question of them and two Medicare expert consultants I have worked with for decades, “If the test reports a positive signal for an unexpected malignancy, will your insurance pay for the diagnostic testing to confirm or refute the labs indication of cancer being present.” They again said, “absolutely not”.

This means that if the blood test suggests the patient has pancreatic cancer, they will now need at least a CT scan of the abdomen with contrast for about $500 and an ERCP procedure including a gastroenterologist, anesthesia, nurse, and a facility fee for about $5000+. These costs will all be out of pocket and non-reimbursable by insurance. If these diagnostic tests fail to detect a malignancy, does it mean there is not one or, does it mean the test is so sensitive that it picked up the tumor prior to it being large enough to be detected? How often will you need to repeat these tests? No one knows yet.

Under the current program design, the findings of the blood test will become part of your permanent health chart and record. What will that due to future attempts to obtain health or life or disability insurance?

I am in no way trying to be negative about a medical breakthrough of extraordinary importance. I am just saying it’s incredibly early, expensive and there are many unanswered questions requiring research prior to being tested.

Why I Switched to Concierge Medicine in 2003

I have been practicing in my independent concierge style practice since 2003. When I decided to switch from a traditional practice to a concierge membership practice, I was examining 25 to 35 patients per day in the office plus about five patients spread between three local hospitals.

At that time, managed care , with the blessing of the Center for Medicare Services (CMS), and private insurers, was flourishing . Patients of mine were now being directed by their employers and insurers to switch to doctors who had contracted with them and agreed to see these same patients for seventy-five cents on the dollar. Lab work performed in my in office “certified” lab was being directed away to national chains like Quest and LabCorp.

To make up the difference in lost income, I was advised to be more efficient and see more patients per day. So, on some days I managed to see 45 patients.

I gave it my sincerest effort in the beginning.  However, it quickly became clear that patients like Mrs. Smith, who joined the practice at age 45 and suffered from an occasional ache and pain from doubles tennis, was now 20 years older. She went from taking an oral contraceptive for perimenopausal hot flashes and irregular menstrual bleeding to being on a low dose of three blood pressure medicines, one cholesterol lowering medicine, two eye drops for glaucoma, one weekly pill for osteopenia and an anxiety / depression pill prescribed by a psychiatrist to help her deal with becoming an empty nester. She went from having two physicians, her internist and gynecologist, to having five or six. Coordinating her care in 5 to 10-minute office visits, advised by the administrative experts promoting managed care, as less expensive meant you never comprehensively covered anything. Thus, it quickly become blatantly obvious to me that taking care of fewer patients very well, by investing as much time as needed to do so, was far superior to taking care of 3,000 patients in a rushed, piecemeal fashion.

Concierge medicine in my practice offers you time and availability. New patient visits are allotted 90-120 minutes to allow the patient and me to get to know each other well. Return or follow-up appointments are generally 45 minutes long. Availability to see your physician, plus time spent being proactive with your care rather than reactive, is proven to improve health outcomes and reduce ER visits and hospitalizations.

During regular office hours, my staff answers the phone not an automated attendant. For after office hour emergencies you have the option of calling my cell phone directly.

Patients phone calls are returned the same day. Requests for prescription refills are completed before the office is closed at the end of each business day. If a health concern requires same day attention, I will see you in the office or send you to the emergency room, depending on the type and severity of the concern. 

By having more time to spend than I did in a regular practice, I am able to advocate for my patients.  I doggedly do so whenever the situation requires it.

When your medical condition warrants you be seen quickly by a specialty physician, we call their office and make the arrangements. We are fastidious in making sure what we call an emergency is actually a medical emergency so when we call and ask for a quick appointment, they appreciate the fact that we respect their time as well as our patient’s.

When prospective patients arrange a complimentary “meet and greet “ session with me. we stress availability, time and advocacy. My staff is customer service trained, oriented and compassionate.  My practice is set in a convenient location with a relaxing atmosphere.

There are fewer and fewer primary care doctors coming out of medical school and residency programs. Most of those that do are faced with six-figure student loan debt and lifestyle pressures which makes an  employed position with a for-profit look appealing. However, their contracts have volume and revenue generating parameters which, if not met, result in termination or less compensation offered the next contract period.

A few enlightened ones find concierge medicine or direct pay membership practices and remain independent so that their relationship with the patient has no insurer drug benefit manager or pre procedure authorization company standing in the way of the health care you and your doctor decide you need!

I began providing concierge-level care in 2003 because at the end of every day you have to be able to look yourself in the mirror and say that you did the best job you possibly could!  Making the decision to change to concierge medicine was the right decision for my patients, and myself, and I’m glad I made it when I did!

Omicron is the Grinch That Stole Christmas

The Center for Disease Control (CDC) is reporting that up to 90% of the infections with COVID-19 Sars 2 Coronavirus are the new Omicron strain. It replicates itself 70 times faster than the Delta strain and contact with an infected person within 12 feet for one or more seconds can result in infection. For those who have been vaccinated against COVID-19 with the Moderna or Pfizer Vaccine, and received a third shot or booster, the expectation is that if they become infected with Omicron, they will either have no symptoms or a mild case. By definition “mild COVID” means your respiratory system is not compromised enough to require hospitalization. Despite this, most of the current deaths in countries which are having a COVID surge are in people older than 65 years of age.

In the past, when patients in this area became infected with COVID-19, we arranged for them to go to the local hospitals to receive an infusion of a monoclonal antibody solution made either by Regeneron or by Eli Lilly. The infusion prevented the infection from becoming severe enough to progress to a severe state requiring inpatient hospital respiratory care. These monoclonal antibodies do not work against Omicron. For this reason, the FDA and CDC have removed the Emergency Use Authorization and ended the administration of these drugs nationwide.

There is a third monoclonal antibody made by Glaxo and Var called Sotrovimab which effectively throttles Omicron, but it is in limited supply. As of today, the State of Florida has received 1050 dosages. Production has been accelerated and hopefully the drug will be available in mid to late January for infusion. There are two new antiviral pills which should work as well. The Pfizer product received FDA approval today and, with production acceleration, some should be available by mid-January. Until these drugs are locally available the medical community has no medications to offer patients who contract the COVID-19 Delta or Omicron variant to limit the severity of the disease.

My advice to my patients and loved ones is to reintroduce distancing and masking. Wear a good N95 mask when you will be around others – especially indoors. If you must be indoors with others, make sure the windows and doors are open and the ventilation is excellent. If there is an air filtration system with HEPA Merv 13 level filters and ultraviolet light that adds protection. Distancing with the aggressive Omicron variant will require 12 feet not six feet.

This is a heartbreaking restrictive change in scheduling and behavior we are asking for at a time of the year when families and friends travel to gather to celebrate. Younger and leaner healthier individuals who are vaccinated will survive this. The real questions are who they will transmit this infection to unknowingly, who is too young to be vaccinated or too old to have a robust immune system?

Our office staff will be reassessing the risk to patients and staff daily. With the local testing positivity rate >10% in Palm Beach County, our contacts will be by phone and telehealth. When the Pfizer anti-viral pill Paxlovid is available, and or Sotrovimab for infusion, we will return to regular in-office patient visits.

I apologize for the inconvenience. Stay safe and call if you have questions.

Phthalates and Early Death

Environmental Health is an online journal that printed the research of Leonardo Trasande, M.D. who practices and works at the NYU Grossman School of Medicine in New York City. His teams’ research found that the death toll and lost working time due to illness from phthalates were far higher than previously thought.

Their study examined middle aged adults between 55 and 64 years during the years 2013 and 2014. The analysis used the data of 5303 adults participating in the U.S. National Health and Nutrition Examination Survey who provided urine samples as part of the study. Phthalates can be measured in the urine and there are known reference ranges of normality. Their research, when extrapolated to the middle-aged population, estimates about 100,000 deaths and forty billion dollars or more lost in economic productivity among 55-64 year old Americans during 2013 and 2014.

Phthalates are a group of chemicals used to make plastics more durable. They are called “ plasticizers” and can be found in personal care products such as soaps, shampoos, hair sprays, fragrances. They are additionally seen in vinyl flooring , lubricating oils and in polyvinyl chloride plastics. These polyvinyl plastic products are seen in food wrappings, garden hoses, medical tubing ( IV tubing). Some of them get into our foods and we eat them and drink them. Some of them are aerosolized and we inhale them. In human beings we see damage to the lungs, liver, kidneys and reproductive organs from phthalate exposure.

Women apparently have a higher urinary phthalate content than men because there are so many of these chemicals in personal care products. There have even been reports of phthalates in infant diapers. Limiting exposure to these chemicals is important but learning where they are and what your risk is remains difficult. This is an area that requires far more timely research and far more transparency.

Concierge Medicine and the Pandemic

Twenty years ago I practiced internal medicine and geriatrics locally in a traditional medical practice. I cared for 2700 patients seen in 15-minute visits with an annual checkup being given a full 30 minutes. The majority of my patients were over 55 years old and many had already been patients for 10-20 years. The practice office revenue was enhanced by having an in house laboratory, chest x-ray machine, pulmonary function lab and flexible sigmoidoscopy colon cancer surveillance program. If patients needed more time, we allotted more time or, more likely, we just fell behind leaving patients stranded in the waiting room wondering when they would be seen. I had a robust hospital practice made easier by the fact that the hospital was a short walk across the street and most of my hospitalized patients came from being required to cover the emergency room periodically for patients requiring admission but not having a physician.

Much changed quickly in the early 1990’s as we approached the millennium. Insurers managed care programs kidnapped our younger patients by approaching employers and guaranteeing cost savings on health insurance by demanding we provide care at a 25% discount. In addition, mandatory ER call became a nightmare because insurers would only compensate contracted physicians to care for their hospital inpatients.

My very profitable chest x-ray machine became an albatross because that $28 x-ray reimbursement was now accompanied by a fee to dispose of the developing fluid by only a certified chemical disposal firm even though the EPA said there was not enough silver in the waste to require that you do anything other than dump it down the sink. The lab closed too. Congress enacted strict testing and over site rules which made the cost of doing business too expensive and not profitable. That flexible sigmoidoscopy went the way of the Model-T Ford when the medical community enlarged to accommodate board certified gastroenterologists certified to look at the entire colon under anesthesia not just the distal colon and sigmoid.

We tried to overcome increased costs and lost revenue by seeing more patients per day. We banded together as physician owned groups owning imaging centers and common labs but the Center for Medicare Services (CMS), which runs Medicare, and private insurers plus Congressional rules on conflict of interest thwarted those ideas. We attended seminars on becoming a member of an HMO and taking full risk for a patient’s health care and cost.

The message was clear, you could make a great deal of money if you put barriers in front of patients limiting access to care and especially in patient hospital care. The ethics of that model did not sit well with many. So, we started earlier, shortened each visit and worked later and harder. As time wore on, and our loyal patients aged, we realized that we needed to spend MORE TIME with them more frequently.  Not less time!

Spending less time with patients was the primary impetus which prompted my exploration of concierge medicine when I realized I was better off emotionally, ethically and morally caring well for fewer patients. Financially, seeing a smaller panel of patients who paid a membership fee generated similar income to maintaining a large panel of patients in a capitated system or fee for service seeing more people with shorter visits.

I discuss this now because I often wonder how I would be able to care for my large panel of patients today in the midst of this COVID-19 Pandemic.

For the most part I have been able to give my patients the time and availability they need to stay safe from Coronavirus and still keep up with the prevention and surveillance testing they need periodically. The 24/7 phone, email and text message access has allowed me to stay in touch with patients – something that would have been near impossible to do in a practice with 2700 adult patients.

I applaud my colleagues who continued in the traditional practice primary care setting despite the fact that most sold their practices to local hospital systems or large investment groups who placed administrators in the care decision-making process dictating time and number of daily visits, referral patterns and products used in the care of the patients.

As an independent physician, I have been able to continue to provide services and referrals that are the best in the area using doctors and equipment I would see as a patient and proudly refer my parents, my wife and children, beloved friends and family members. I am able to guide patients based on evidence and quality of measures not only what is most cost effective. I have no contract with a health system that requires me to see a certain number of patients per day, per week, per month or face a drop in salary or dismissal. I am proud and fulfilled at the end of the day because I can look in the mirror and know that I tried my best for the patients.

I additionally have the ability to say “no” to a potential new patient that I believe would not benefit from being in my practice for numerous reasons. Providing time to meet potential new patients gives both the patient and physician an opportunity to assess whether developing a professional relationship would be a good fit for both.

During the pandemic these meetings have become tele-health virtual meetings which are far more impersonal and less educational for both the potential patient and the doctor. It is still far better than having an administrator schedule a new patient, with no questions asked, on your schedule with the only criteria being can they pay the price?

Sadly, this horrible SARS 2 Coronavirus pandemic has made concierge internal medicine and family medicine more attractive than less. Having your physician available to discuss prevention, vaccines, testing methods and locations and treatments, if infected, is much easier in these membership practices than in a traditional practice where your phone calls are routed through an automated attendant phone system, reviewed by a non-physician provider and handled usually by a nurse practitioner or physician assistant with only the most serious and complicated situations reaching the physician’s desk.

I predict that more and more patients will seek concierge care in the next few years because patients are getting tired of fighting the bureaucracy and struggling to get the attention of their health care providers when they think they need it.  But don’t blame the providers.  It’s the dysfunctional, inefficient and profit driven corporate system that has created this situation.

Safety for Patients First

In the heat of the ongoing pandemic, my associate and I suspended in-person routine office visits for the safety of our patients. To get to our office, patients walk through a revolving glass door into a common lobby and then take a small elevator up to the second floor. There are stairs which are well hidden and not easily accessible. A sign is posted next to the elevator suggesting facial covering, but not requiring it, despite an executive order in Palm Beach County mandating their use.

This is a multiuse building with numerous offices. Many of the other tenants do not social distance or wear masks routinely. There have been multiple tenants who have tested positive for COVID. For this reason, we participated in telehealth visits exclusively to protect our older, chronically ill and vulnerable patient population. It was safer to keep them in their home than bring them into our practice. We were willing to forego practice revenue and income to do so. Our first priority is the safety of our patients.

The office has been open daily, answering calls, refilling prescriptions, filling out forms and scheduling telehealth visits. The criticism from patients for doing this has been scathing. The worst criticism has been from those requesting blood draws for visits to other doctors. We performed this as a courtesy in Pre- COVID days but believe the risks far outweigh the benefits for non-ill individuals at this time.

The COVID-19 hospitalization rate and percentage positive rate locally have declined to a level that is allowing us to begin safely seeing patients again in our office. The building management still will not enforce the Palm Beach County mask mandate so we urge you to social distance and wear your mask.

Do not enter the elevator unless it is empty. Wait for the next one to ensure safety. Hope to see you soon. Call with any questions.

Testing in Pharmacies, Another “Duh” Moment for Florida’s Governor DeSantis

At his coronavirus pandemic news conference, the Governor of Florida, who last week defined professional wrestling as an essential business, announced that testing for COVID-19 will be expanded by using pharmacies as test sites. He indicated the details still need to be worked out.

In the absence of a Federal plan for testing, states like Florida, which are desperately trying to reopen for tourism and business, are attempting to figure it out themselves. I just raise these simple questions:

  1. Who will be performing the testing? Will it be the same pharmacy techs that take 30 minutes to give a vaccination that can be administered in five minutes or less elsewhere? Will they hire nurses? Medical assistants? Moonlighting EMS personnel?
  2. Which test for COVID-19 will they be using? If it requires a nasopharyngeal swab will the personnel have adequate personal protective gear? Will it be sent to a lab? Will it be a quick on site test? If 100 people with COVID-19 took the test how many would test positive? If 100 people not infected with COVID-19 took the test, how many would falsely test positive?
  3. Who will train the pharmacy personnel on how to correctly take a deep nasal sample?
  4. Who will train the pharmacy personnel on how to dress in the personal protective gear and sanitize between test subjects so that they do not expose the non-infected, or next test subject in line, to COVID-19 or expose themselves?
  5. Where in the pharmacy will this be done? Will it be a drive thru in the parking lot? If it is in the pharmacy how will you protect healthy shoppers from potentially sick patients? How often will each store need to be disinfected and how will they do it?
  6. Who will pay for the cost of testing?
  7. For those who test positive, who will be responsible for reporting it to Public Health? Who will be available and responsible for tracking down contacts of infected patients?
  8. Will the testing only be done by appointment at specified times?
  9. Will the pharmacies have the same limited test supplies that has prevented appropriate recipients from being vaccinated for shingles with the Shingrix vaccine?

The State of Florida, through decimation of its Public Health system due to inadequate funding under former Governor, now Senator Rick Scott, is reeling from an inability to respond, test and treat the poor and underinsured of Florida. They once again turn to an inexperienced and untrained private sector to assume their responsibility.

There is Still a Pandemic in Florida Folks!

I opened the local newspaper to headlines that the Palm Beach County Commission has opened county facilities but is not requiring visitors to wear masks, facial coverings or observe social distancing rules.  A county commissioner was quoted as believing that it was not within their authority to require facial coverings.  Strange opinion when they have closed businesses , facilities and services due to COVID-19 and then reopened them independent of Public Health, CDC or even White House guiding rules and regulations and published the conditions under which these facilities will open and operate.  I imagine, or hope, the County civil servants have union representation that will address the issue of their employees being called back to work with their health and safety being taken for granted.

Recently, I spoke to a patient who believes COVID-19 is overblown. They are closer to 80 years old than 70, continues to smoke tobacco regularly despite having documented coronary artery disease and is incensed that the free flow of patients has not restarted in our medical practice.

I keep coming back to the same question.  Despite our Governor opening the state up again, what has changed medically or scientifically?

  1. We still do not have an onsite quick accurate test to determine if a patient has COVID-19 and is a contagious asymptomatic carrier. Yes, testing sites have increased but most test results come from a lab with a 48-hour wait delay.  Our local medical center, Boca Raton Regional Hospital Baptist Health system has on the physician website a request to only perform quick in-house COVID-19 testing one time on admitted patients only because they do not have enough supplies on hand.  Patient’s presenting to the Emergency Department still receive a nasal swab which is sent to an outside reference lab and results take 48 hours.
  2. We don’t have enough personal protective equipment for hospital staff to change masks, capes, face shields and gloves according to their own guidelines for treating an infectious patient and preventing transmission of the pathogen to others, including you! In view of the shortage of equipment, the CDC and hospital infectious disease departments have relaxed their own guidelines several times to ensure their guidelines agree with the way equipment is being used.
  3. We still do not have a treatment other than supportive care. Yes, there is some evidence that remdesevir early in the course helps and that a triple drug regimen in more severe cases helps.
  4. We are still months away from having a vaccine.

In Palm Beach County, civic leaders admit they bowed to the pressure of struggling businesses, distressed parents out of work, and home with school age children, and political pressure from Washington and Tallahassee in deciding to open the economy back up.  With Palm Beach County opening May 11th and Dade and Broward County on May 18th, we should begin to see an increased infection rate over the next two weeks based on the incubation period of COVID-19 and its complication rate developing around Day 8 or 9.  

I sincerely hope I am wrong about this, but my infectious disease colleagues, critical care colleagues and Emergency Department colleagues have shared this professional opinion with me.  This disease infects and kills youngsters, young adults, teenagers as well as senior citizens.  Asymptomatic carriers of the COVID-19 bug infect 5.7 individuals before they discover they are sick. 

Despite this, we ask county employees and restaurant servers to spend time up close with no requirement to wear a facial covering.  Tell me, what has changed other than the level of patience of our elected officials and their overwhelming desire to gain public favor and get re-elected regardless of the health care costs and carnage from COVID-19?