Hi, I’m back as Robin-Schoenthaler-the-Boston-cancer-doctor-who-writes-about-Covid.

(And it’s okay with me if you want to share.)

Today I’m talking about Covid risk factors including obesity and at-home testing and how I stay upbeat.

Numbers have edged up again in Massachusetts.  The rate of positive tests has gone from 1.4% to 2.2%, scaring the absolute wiggle out of many of my colleagues who still have PTSD from the front line nightmares of April and May.  I wouldn’t be surprised if we have to reverse the “openness” of Phase 3.  Not another lock-down, but definitely a dial-back.

How do you dial back? 

Some places with rising cases have responded by re-closing bars, gyms or casinos, reducing dining-in capacity, making masks mandatory in more places or reducing the numbers of people that can get together. 

That could definitely happen here. 

A bunch of other countries have outlawed alcohol except in certain settings.

I don’t see that happening here. 

The other thing that happens when numbers go up is people start self-isolating again, more intently, more mindfully.  People who are at higher risk try harder to take fewer chances. 

Who does the CDC say is at the very highest risk?  People who are “older” (higher risk every decade) or who have:

  • serious heart conditions (heart failure, cardiomyopathy, coronary artery disease)
  • COPD/emphysema
  • chronic kidney disease
  • current cancer (it’s not known if past cancer increases risk)
  • diabetes type 2
  • sickle cell disease
  • prior organ transplant (eg kidney or liver) with current immunosuppression
  • and obesity, defined as BMI>30

I want to talk about obesity despite the fact that anytime I mention obesity I get pushback about whether this is fat-shaming or why BMI measurements are lousy.

I feel compelled to again bring obesity up because it is one of the only potentially modifiable risk factors and because it has been repeatedly found to be a significant risk factor since the very start of the US pandemic, and it’s still way up there. Over and over the science shows people who have higher BMIs — regardless of whether they do or don’t have the other chronic conditions listed above — have a higher chance of bad Covid and a higher chance of dying from it.

Again, this isn’t about judgment; there just seems to be something about obesity that leads to worse illness.  Maybe people with more weight have more ACE receptors in the lungs for Covid to bind to, maybe the hormones fat cells make cause increased susceptibility, maybe it’s something to do with insulin resistance  — we just don’t know yet.  All we know is the data: having a higher BMI puts people at higher risk of trouble.

So maybe some of us bigger people should seriously consider going to see a weight loss doctor.  There’s all kinds of newer meds now, they know a LOT more about obesity than they used to (half the hormones they talk about now weren’t known when I went to med school), bariatric surgery can be a life-saving miracle, heaven knows this Covid data is motivating, and every little bit helps.

Moving on to a totally different topic, sometimes people ask me how I stay upbeat during the worst of this.  Two things, I think.

First off, I’m a student of epidemics and the one thing we know about even the worst of epidemics is that they always wind down. So I keep my eye on that historical ball.  Somehow or other, All Epidemics Always End.

The other way I stay positive is I virtually never watch mainstream and clickbait news and try very hard to not “doomscroll” through Facebook or Twitter.  I instead get most of my information directly from scientists (listening to podcasts, watching Grand Rounds, etc). 

The amazing work researchers and doctors have done and are doing is just absolutely inspirational.   They’re scientifically testing idea after idea after idea, and one of these days one of those ideas is going to work. 

The last few weeks I have become increasingly taken with the idea of instant at-home testing.  What if you could get up in the morning, spit on a piece of paper, and find out that minute whether you have Covid?  How cool would that be? 

This is how cool it would be: 

a) The test is positive.  You stay home.  You don’t go to school or work or lunch with Great Aunt Bertha.

b)  The test is negative.  You go out into your world with a good deal of confidence that you are not a danger to anyone, most particularly Great Aunt Bertha. 

A test like this could change everything. 

So why don’t we have this? 

A huge reason we don’t have it is because the FDA has thus far required that Covid tests (eg PCR tests from the nose or back of nose) be super-dooper-completely sensitive at detecting even teeny weeny pieces of Covid. (The famous false negatives can be because of timing or technique.)

But the science is showing us that teeny weeny amounts of viral material aren’t necessarily contagious. You seem to be contagious only when you have a BIG bunch of viruses.

So what we need is a test that shows when you have a BIG bunch of viruses in you — ie when you are contagious — not just when you have a little bit of non-infectious viral RNA stuck in your nose.

So maybe the test doesn’t have to be as sensitive as a clinic test.  Maybe it can be orders of magnitude less sensitive.  Maybe we can skip the “perfect test” part and just go straight to “good enough.”

The other thing we need is for it to be fast.  Right now turn-around times for tests are hideously long — some as long as quarantine (10-14 days)!  A good test must be fast, and a useful at-home test has to be essentially immediate, like a pregnancy test. 

So if we could all have a simple, spit-oriented, “good enough” test to let us know we were safe or unsafe, and it was cheap enough to do every 24-48 hours — wouldn’t that rock?  No more lock-downs, no more fretting about the dangers to teachers and front-line and health care workers, and no more worrying we are riddled with Covid and going to be the death of Great Aunt Bertha.

We don’t have that test now.  It hasn’t been invented or tested or proven or anything.  But it’s yet another interesting idea that smart people are working on.

And one of these day one of these ideas — a test, a treatment, maybe even a vaccine — is going to work. Because, I promise you, history bares it out: All Epidemics Always End.