A View from the Vaccine Front Lines

Note: The following essay was written by my husband, Gary Bakst, a physician in New York’s Capital Region. Thank you, Gary, for sharing your experience and insight.

It has been a miserable year for all of us dealing with COVID-19.  The virus has killed over 500,000 Americans and infected about 30 million of us.  Some are still dealing with “long haul” symptoms, ongoing effects of the virus.  Sadly, many have lost loved ones to this scourge.  By now, very few of us do not know someone who has had it. 

Beyond the illness itself, the precautions being taken to prevent infection have entirely changed the way most of us live.  We are mostly staying home, working remotely, and avoiding gatherings.  There are no concerts, no theater, no ballgames.  Many of us are not willing to go to restaurants, bars, health clubs or yoga studios. 

For those of us still working in person, teachers, grocery workers, and health care workers, etc., there is the real risk of infection.  And in our office, that concern has similarly been significant.  There are about 90 employees in our office.  We represent substantial diversity in all kinds of ways:  race, age, religion, rural vs. urban, health status, educational and economic status. 

And we have about 300 people who come into our office on a daily basis for doctor’s appointments, to see physician assistants, nurse practitioners, diabetes educators, podiatrists or our surgeon.  They come in for labs and ultrasounds and bone density measurements.  It is a lot of people and a lot of appointments.  Altogether, since the beginning of the pandemic, it represents about 80,000 visits. 

Given the prevalence that COVID has had in our community, it was inevitable that, at some point, people who work in our office would test positive for the virus.  Yet, through the end of November, we had not had one employee test positive.  Our precautions were working. After the Thanksgiving vacation, that started to change. We had first one and then several and then a substantial number of employees test positive.  By and large, it did not feel like transmission was happening within our office although there was quite a bit of worry over that possibility.  Mostly, it was people who presumably became infected outside of work, possibly via contact with asymptomatic people who did not know that they were carrying the virus.

We had at least one example of a physician acquiring infection from contact with a patient who did not know they had the virus.  Personally, I had two consecutive Fridays in which a patient called (or a family member of that patient) that they had tested positive the day after their visit.  Sometimes people just don’t really think they have COVID – maybe they had minor symptoms and got tested but they answered our prescreening questions indicating no such issues. Getting those Friday calls led me to quarantine apart from Linda and certainly raised my anxiety level. Fortunately, I didn’t get the virus and neither did Linda.

Unfortunately, some of my patients have been very seriously ill with COVID-19 and several have died from it.  Many of them were lovely, sweet people with wonderful families.

Most of the employees who tested positive had minor symptoms or were asymptomatic.  Several were more significantly ill.  Several had to miss work for weeks or even months.  Those who were sicker longer have had some issues in terms not feeling entirely themselves even after returning to work. One of the many frustrating things about this pandemic is the unpredictability of the disease.

By early January, I had reached the point where I was seriously thinking that we needed to shut down the office for 10 days.  Then, the vaccine took effect.  I got my first dose on December 28th. It was 2 weeks after we received the first dose that all of this stopped.  Not all of our employees chose to get vaccinated, but the overwhelming majority did. 

Up until that point, the tension, the fear, in the office was palpable among many of our staff. Everyone handled it in their own way.  Some were clearly less concerned, and a few had to be repeatedly reminded to keep their masks on. 

Albany Medical Center saw up to 38 employees test positive on a single day in that period.  After vaccination – just over 90% of their employees chose to receive the vaccine – that number fell to either zero or one positive test per day.  Most of the employees who tested positive were those who chose not to get vaccinated. 

In terms of side effects, many of our staff did have some side effects.  Half of us received the Pfizer vaccine and half Moderna.  I did not notice any difference between those two vaccines in terms of side effects.  I personally only experienced mild arm pain with both doses (of Moderna).  But many in the office had more side effects with the second dose.  Some had fever and chills, some were achy, some had nausea, some were exhausted.  These effects generally lasted typically 12 to 36 hours.  I do not know of anyone in the office who had anything worse or anything that lasted longer.

There have been several concerns that people have raised regarding getting vaccinated.  I want to briefly comment about them:

  1. “They were developed too quickly – something must not be up to standards.”  Actually, they were subjected to exactly as much testing as all of the other vaccines that are produced, it was just that certain steps were done in parallel rather than sequentially.  While all kinds of factors allowed it to be brought to the public more quickly including the promise that our government would pay for many doses, no vaccine went to market until all of the usual safety and efficacy studies involving tens of thousands of people were completed. All three vaccines have been authorized by the FDA.
  2. “Since political pressure was brought to the process it must be tainted.”  While there has been all too much politics involved in so many aspects of our response to the pandemic, those in charge of the vaccine process, thankfully, resisted pressures to short cut the steps we take to ensure that these vaccines work and that they are safe.
  3. “The new technique of using RNA to make a vaccine means that my DNA will be altered or somehow there will be long term effects of the vaccine”.  The messenger RNA does not get into the cell nucleus and does not ever do anything to our DNA.  It is degraded fairly quickly and does not persist in our bodies.  mRNA vaccines have been used before and have been safe and effective.  However, never before has an RNA vaccine been used on this scale so it is absolutely reasonable to continue to monitor for potential adverse effects. 

We are now many months since the first volunteers received the vaccines and their safety record has been very impressive.  Their efficacy has similarly been very impressive as seen in our office.  And the disease that we are combating is dangerous.  We will not overcome it without vaccine.  More than 500,000 Americans have died from it.  With over 50 million Americans vaccinated, not one person has died from vaccine.  The risk of vaccine is so clearly low and the risk of being unvaccinated so very clearly intolerable, even tragic. 

Personally, I am so very grateful to be vaccinated.  I feel less vulnerable and less likely to infect other people.  Being vaccinated has not yet had much effect on the things I choose to do or not to do.  I am still quite careful at work and reluctant to go to places where people gather.  But I am hopeful that much of this will change as more of the people I know receive vaccines and I am encouraged that the availability of those lifesaving shots is increasing week by week.  I hope you are able to access a vaccine soon or have already had one and that it makes your life better and safer. 

Funny Jokes and Serious Matters

Note: This is a guest post by my husband, Gary Bakst, M.D. While I may question whether the jokes are funny (Gary didn’t write them!), I don’t question the seriousness of the subject he addresses. Thank you, Gary.

Jewish Humor – here are some jokes that have been around longer than I have:

  1. Why don’t Jews drink? It interferes with their suffering.
  2. My wife will buy anything that’s marked down. Yesterday she brought home two dresses and an escalator.
  3. A man can’t find a lawyer. He picks up the Yellow Pages and picks out a law firm-Schwartz, Schwartz, Schwartz and Schwartz. He calls up and says, “Is Mr. Schwartz there?  A guy says, “No, he’s out playing golf.” The man says, “All right, then let me speak to Mr. Schwartz.”  “He’s not with the firm anymore.”“Then let me talk to Mr. Schwartz.”  “He’s away in Detroit.  He won’t be back for a month.”“Ok, then let me talk to Mr. Schwartz.”  “Speaking.”
  4. I’d like to help you out. Which way did you come in?
  5. In New York’s Garment District, a little, old man is hit by a car. While he is waiting for an ambulance, a police officer tucks a blanket under his chin and asks him, “Are you comfortable?”  The man responds, “I make a living.”

It is that final joke that I am thinking about as I write this essay.  I grew up in a middle-class family and in a middle-class neighborhood. I remember when Linda and I struggled to make ends meet.  I realize that we are more comfortable today, but I still like to think that I am connected to the struggle of the average person/average family.  The reality is, every so often a patient says something that reminds me that I am not as connected as I’d like to believe.

They will tell me about the cost of an item – perhaps $10 – that is a big deal in their lives.  They are living on fixed incomes or small paychecks.  They have worked their whole lives but cannot afford things that I would take for granted.  While every expense is important, the one that we are most often speaking about is the cost of their medication.

This is a problem that has been mentioned often in the media.  But I don’t think that the real impact on so many people has been adequately discussed.  The stories I see in the news are about the most extraordinary examples.  They don’t convey the reality that I see people face numerous times every day.  The reality is, especially in the world of diabetes care, that we are in a time when there are great medications that can change people’s lives.  They can safely lower their glucose levels, protect their hearts and their kidneys, prolong their lives.

On the other hand, I have never seen a time in which so many people just couldn’t afford their medications.  It was not that long ago that medications were prescribed by doctors and filled at pharmacies and patients picked them up for no copay or small ($5-10) copays.  Now, the doctor writes the prescription and it goes to maybe a pharmacy, maybe a gigantic mail order facility.  The insurance company rejects the charge but doesn’t tell either the doctor or the patient why the med was rejected or what alternative would be covered.

Our staff spends enormous, frustrating hours, expensive hours, working on getting medications approved.  When a medication is approved – not necessarily the medication we had ordered but some theoretically similar drug – the patient is still left with frequently gigantic out of pocket expenses.

Some of this is related to the fact that medications are so much more expensive than they used to be.  The pharmaceutical industry is entitled to make their profits and needs substantial income in order to invest in the next generation of medications.  But too much of that profit comes from the US (as compared to overseas markets) and it seems like the average American is carrying a financial burden that is breaking their back.

On top of this, the insurance companies routinely reject claims, use intentionally opaque methods to keep us and our patients in the dark about what they need in order to approve those claims and even when they cover the medications, they leave too much of the charge on the shoulders of the patient.

Insurance companies typically use ever increasing premiums to herd patients into high deductible plans.  This means that you pay your premiums, but the insurance company may never spend anything on your care.  The situation is similar for those who receive their insurance through the Affordable Care Act (Obamacare).  While it is great that there is insurance that people can access, the insurance is often expensive and comes with high deductibles.  And, for those who get their insurance through Medicare, the development of prescription drug coverage (during the George W. Bush administration) is a great step forward but the coverage comes with that so called “donut hole” which means that you have to pay thousands of dollars out of pocket and then you can get back to where the coverage helps you out.

In the end, we are at a time of crisis in health care affordability and especially medication affordability.  Recognizing that I have no expertise in this topic beyond what I see every day in my office, I would make several suggestions that I do not hear from our politicians of either party.

  1. I would end the policy of not allowing Medicare to negotiate with pharmaceutical companies regarding the price of medications. Medicare needs that tool.
  2. Congress needs to pass a law limiting how much more any medication can cost in the US as opposed to the rest of the developed world. Perhaps up to 20% more but not the 300% more that we often see.
  3. I would outlaw deductibles over $1000
  4. I would limit how terrible any insurance policy can be and still be legal to sell in the US. If you are marketing your policy as insurance, it has to be helpful to people when they get sick or injured.
  5. I would require insurance policies to offer adequate reimbursements to hospitals such that they can hire enough nurses to truly take care of patients. Patient to nurse ratios are becoming dangerous and patients will be harmed.
  6. I would increase reimbursement to doctors and other health care providers for primary care services. This would continue the trend of reduced reimbursement for procedures and presumably make more doctors consider careers in primary care – not enough doctors are going into primary care.
  7. I would require insurance companies to make public how much money they spend on items other than patient care and to make public their procedures for approval of tests such as PET scans and for medications and expensive treatments. It is time to remove the curtain and give doctors and patients a fighting chance to get patients the care they deserve.
  8. Medicare is more efficient in translating money into care and I would require private insurance companies to make strides towards that benchmark in order to operate in the US.

There it is. That is my little manifesto.  The rantings of a comfortable doctor on behalf of his uncomfortable patients.  Now one last Jewish joke:  A Jewish grandfather takes his grandson to the beach when, suddenly, a gigantic wave sweeps the boy away.  Panicked, the grandfather looks up and prays to God, “Oh God, please bring him back.  Let him live.”  Just then, an even larger wave deposits the boy back on the beach unharmed.  The grandfather looks up and says, “He had a hat.”