Thursday, November 18, 2021

A firefighter’s experience with bariatric weight loss surgery

From Fire-Rescue 1 Nov 18, 2021

“Rates of overweight and obese individuals in the fire service are higher than those found in the general public, ranging from 73 percent to 88 percent of firefighters.”

This disturbing finding comes to us from the National Volunteer Fire Council.

Other major fire service organizations have come to similar conclusions, with further research showing the outcomes of our poor health. The National Institute for Occupational Safety and Health (NIOSH) reports that in 2019, over 50% of all line-of-duty deaths (LODDs) were the result of sudden cardiac arrest.

"Throughout my fire service career, I constantly felt that I had to work harder and do more simply to break even with the 'in-shape' firefighters," writes Philip Clark. (Photo/Philip Clark)

We’ve been hearing these stats for years – but that doesn’t always mean we take action to avoid becoming a statistic ourselves.
“I was falling behind”

I cannot remember a time in my adult life, or most of my childhood for that matter, that I was not overweight. It was a constant struggle. I ate from boredom, I ate from depression, I ate just to eat. I did not have healthy habits.

Slowly I went from husky to chubby to big to fat to morbidly obese. Much like a frog in a pot of heated water, the change was so gradual that I didn’t notice it was killing me. I didn’t wake up one morning overweight; it was a series of bad choices and poor self-care that led me to my own downfall.

Throughout my fire service career, I constantly felt that I had to work harder and do more simply to break even with the “in-shape” firefighters. But if I was being honest with myself, I wasn’t breaking even. I was falling behind. My crew would have to work harder to complete the task because I wasn’t keeping up. I remember a time when working at a structure fire would be the only event of my day because I was physically spent after the call. I realized that I was putting not only myself but also my family and my fellow firefighters at risk.

The sobering statistics above, along with several personal realizations, led me to make a life-altering decision. I needed to make a change. I needed to start taking my health seriously.
“Preparing for the rest of my life”

In June 2020, I started the process of meeting with a bariatric center for weight loss surgery. The process, as I would learn, was more involved than I had realized. I would spend the next three months preparing for the rest of my life. I met with a dietician to discuss my eating habits, and together, we created a plan for success. I met with the surgeon who laid out all the requirements for my surgery to take place. I started a diet almost immediately following my first appointment, and over the next few months, I had regular checkups with my team to ensure that I was sticking to the plan.

At two weeks out from the surgery, I was put on a full liquid diet that consisted of creamed soup, yogurt, pudding, Jell-O and protein shakes. At the time, I was working a full-time night shift in a busy 911 system. Meal prep was a must because, as you can imagine, there aren’t many options for a liquid diet from a gas station at 3 a.m.

Finally, in October, the day came that changed my life. I joined the “Loser’s Bench.”

The surgery was simple enough, at least according to the doctors. Through five small incisions in my abdomen, they would remove around 80% of my stomach, essentially turning my stomach from a ball shape to a banana shape. The surgery not only creates a smaller “pouch” for food to fit in to but also suppresses appetite. The doctors projected that I would lose 75-80% of my excess weight simply from the surgery. The rest would be up to me and the lifestyle changes I enacted.
“The weight began to come off”

Recovery went well. My first two weeks after surgery required a clear liquid diet. This is like the full liquid diet, but it removes any liquid you cannot see through. If you’re thinking that this sounds unenjoyable, you’re right! I lived off of Jell-O and beef or chicken broth.

"I had cinched up my turnout gear as much as I could, but after losing 50 lbs., I looked like a little kid wearing his dad’s suit for dress-up," Clark said. (Photo/Philip Clark)

As the days passed, the weight began to come off.

For the next two weeks, I was back to the full liquid diet. By the end of my first-month post-op, I was allowed to eat soft puréed food. Let me tell you, chicken mush never tasted so good! By this time, I had lost about 25 pounds, and I was beginning to see and feel the changes.

January brought more good news. I was down about 50 pounds, and my clothes were starting to sag off my body! Even more impressively, I was starting to realize the difference that this weight loss was going to make. I wasn’t winded as easily. I had more energy. During training, I had more to give. I had cinched up my turnout gear as much as I could, but by this point, I looked like a little kid wearing his dad’s suit for dress-up.

As the pounds kept coming off, my mental health began to improve as well. I started to feel better about myself on both the outside and the inside. It was a whole new experience for me, but the best was yet to come.
“Is this how healthy people feel?”

By early summer, I was down almost 100 pounds. It was at this point that two very big events occurred – eye-opening events in my weight-loss journey.

The first was a working fire that just a year ago would have wiped me out and required at least a day of recovery. I found that I was able to make my SCBA breathing air last longer and that I didn’t feel as tired afterward. It was amazing to me that I had more to give when the job was done! Is this how healthy people feel?! Even though I am a paramedic, I had no idea that my extra weight was putting such a strain on my body, and I couldn’t believe that I had waited this long to take on this problem head-on.

The second event was the physical agility test for the career department to which I had applied. In the past, I talked myself out of these kinds of tests by making excuses – all out of fear of failure. I would wait to get the medical release signed until it was too late. I would make sure I was working on the day of the test and that I “wouldn’t be able to get off.” I was trying to protect my pride by making sure that if I didn’t take the test, I wouldn’t fail. On the day of the test, I was more confident and felt better prepared than I had felt about anything in a long time. It was hard, but I passed! Not only that, but I passed with a significant amount of time leftover! After successfully passing the agility test and the interview process, I was hired to be a full-time firefighter.
“You need to make the choice”

This journey has been hard. I still struggle with emotional eating, and I work every day to try to better myself. I find that there are days when I backslide, but it only takes a quick trip down memory lane through my photos to see how far I have come and to remember how much I do not want to go back to where I was.

I would like to encourage everyone reading this to take a moment to perform a self-assessment. Ask yourself the following questions:
“If my loved one – my daughter, my son, my spouse, my parent – was trapped in a fire, would I want ME being the one to have to make that rescue?”
Could you, without a doubt, do the job?
Could you give it your all and still have some left over?

If the answer is no, there is only one person who can fix it. You need to make the choice to make yourself better.

There is a quote from Greek philosopher Heraclitus that says the following: “Out of every one hundred men, ten shouldn’t even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them, for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back.”

Are you one of the 10 that shouldn’t be there, the 80 who are just targets, or are you the one? I may not be the one – I don’t think that anyone can label themselves as such – but I am now confident that I am one of the nine real fighters. I will continue to strive every day to be the one, and to never go back to being one of the 90 ever again.

So come with me, and together we can achieve our goals. Believe in yourself. BE THE ONE!

Sunday, November 14, 2021

Wednesday, November 10, 2021

Unvaccinated Texans 40 times more likely to die of covid than those fully vaccinated in 2021

From the Washington Post

Unvaccinated Texans 40 times more likely to die of covid than those fully vaccinated in 2021, study says
Paulina Firozi1:23 p.m. EST

A medic from the Houston fire department prepares to transport a covid-19 patient to a hospital on Aug. 24. (John Moore/Getty Images)

A vast majority of Texans who have died of covid-19 since the beginning of the year were unvaccinated, according to a grim new Texas health department report released Monday.

The report from the Texas Department of State Health Services examined data from Jan. 15 to Oct. 1 and found that unvaccinated people were much more likely to get infected and die of the coronavirus than those who got their shots.

Of the nearly 29,000 covid-linked fatalities in Texas during that period, more than 85 percent were of unvaccinated individuals. Nearly 7 percent of the deaths were among partially vaccinated people, while nearly 8 percent were fully vaccinated.

The figures highlight just how much more at risk the unvaccinated population has been this year: In all age groups, the state’s unvaccinated were 40 times more likely to die than fully vaccinated people. The study also found that the unvaccinated in all age groups were 45 times more likely to have a coronavirus infection than fully vaccinated people. It also looked closely at data from September and underlined the impact of the highly contagious delta variant, which fueled a surge in Texas, as it did in much of the country.

The report from Texas health officials underscores the risk that cases and death counts would spike among the unvaccinated, echoing the alarms that public health officials have been sounding throughout the year. The report, which Texas health officials say is the first statistical assessment of the real-world effect there of vaccination against the coronavirus, also highlights the impact in a state where Republican leaders have sharpened attacks on public health strategies throughout the pandemic. Last month, Texas Gov. Greg Abbott (R) banned any entity in the state from mandating vaccines for workers or customers.

“This analysis quantifies what we’ve known for months,” Jennifer A. Shuford, the state’s chief epidemiologist, said in a statement. “The COVID-19 vaccines are doing an excellent job of protecting people from getting sick and from dying from COVID-19. Vaccination remains the best way to keep yourself and the people close to you safe from this deadly disease.”

Shuford’s remarks echo statements from other health leaders, including Rochelle Walensky, director of the Centers for Disease Control and Prevention, who has described the nation’s ordeal as “a pandemic of the unvaccinated.”

While Texas is still averaging more than 3,200 new daily infections and almost 110 deaths a day, the state, like the nation overall, has seen case and death totals fall, according to data tracked by The Washington Post.

Nearly 54 percent of the state’s population is fully vaccinated, trailing the national vaccination rate of 58.4 percent.

The state data “shows what we already knew — that the unvaccinated are increasing their risk of severe covid disease and death, and we have the data now to prove this,” said Bhavna Lall, a clinical assistant professor at the University of Houston College of Medicine.

She said she’s troubled by leaders questioning public health mitigation measures and vaccination mandates, particularly in a state that’s had more than 70,000 deaths since the pandemic’s start — one of the highest total death counts in the country.

“By debating mitigation measures, we’re not helping in any way,” she said. “We know what works for decreasing the spread of covid. We know that vaccination works, we know masking works.”

Recent findings from the CDC similarly highlighted risks for the unvaccinated. A CDC study published in September found that people who were not fully vaccinated in the spring and summer were more than 10 times more likely to be hospitalized and 11 times more likely to die of covid-19 than people who were fully vaccinated.

Unvaccinated people were 11 times more likely to die of covid-19, CDC report finds

The new report from Texas also breaks out findings from the weeks between Sept. 4 and Oct. 1, which the health department said researchers wanted to analyze to measure the vaccine’s effectiveness as the delta variant surged in the state.

In that time frame, unvaccinated people were 20 times more likely to experience a covid-associated death than fully vaccinated people, and were 13 times more likely to become infected with the virus than the fully vaccinated.

The Texas data strengthens scientists’ assertions “that vaccines work,” said Rama Thyagarajan, an assistant professor at the University of Texas at Austin’s Dell Medical School.

She noted that the small percentage of fully vaccinated Texans who died probably were “the oldest and sickest of the group.”

The report said 35 percent of deaths were among people 75 years and older, and 25 percent were among those 65 to 74.

While the vaccination against the coronavirus had a strong protective effect for all people, the report notes, the findings varied by age on the protective impact for covid-related deaths. Unvaccinated people in their 40s were 55 times more likely to die of covid-19 in September than fully vaccinated people of the same age. For people age 75 and older, the unvaccinated were 12 times more likely to die than the vaccinated in that time frame.

The report also highlighted the severity of the impact of the delta variant overall. Regardless of vaccination status, the report says, Texans were four to five times more likely to become infected with the coronavirus or to suffer a covid-linked death in August, when the variant was prevalent in the state, than in April, before its presence was widespread.

Lall said it was “sad to see that during the time when delta was surging, we had so many people … dying because they just didn’t get the vaccine.”

She said the latest report from Texas, which shows the protection offered by vaccination, underlines the need to encourage not only more vaccinations but public health measures that can help stop the virus from surging.

“We need to be aware that other parts of the world are surging — Europe has high covid cases right now — and if we don’t get more people vaccinated in America, we’re still at risk,” she said, adding: “No one wants to go through these surges again and again.”

Saturday, October 23, 2021

As coronavirus cases mount and vaccine mandates spread, holdouts plague police and fire departments

Washington Post
Mark Berman October 2, 2021, at 9:00 a.m. EDT

When the coronavirus vaccines were first rolled out, the national Fraternal Order of Police went to the federal government, pleading for law enforcement officers to have “expedited access” to the shots. Police, the group wrote, needed the vaccines “to keep them, and the public with whom they interact, safe from infection.”

But to the group’s surprise, officers did not rush to get the shot. And months later, with the vaccines widely available across the country, scores remain unvaccinated.

“We worked very hard, along with others, to ensure that police officers had early availability on a premise that they’d all want it,” said James Pasco, FOP executive director.

Nearly a quarter of Americans age 18 and older remain unvaccinated, according to a Washington Post analysis of federal data, frustrating officials and fueling bitter debates. Yet the continued resistance among the first responders included in those tens of millions is particularly troubling and creates a different kind of threat, experts say.

Foxboro Police Officer Brendan Fayles checks in at the Putnam Clubhouse at Gillette Stadium in Foxboro, Mass. to receive his coronavirus vaccination on Jan. 15. (Mark Stockwell/AP)

Due to the nature of their jobs, first responders regularly have close contact with the public, which increases their risk of contracting and spreading the coronavirus among themselves, their families, and the people they are sworn to protect, experts in public health and policing said.

“They’re going to get infected because they have more contact with people than most,” said Vincent Racaniello, a professor of microbiology and immunology at Columbia University. “It doesn’t work any other way.”

Changing recommendations for boosters leads to confusion for the vaccinated and their doctors

The resistance to vaccination is surprising, some said, given how the virus has battered law enforcement’s ranks since the beginning of the pandemic and continued to do so as the delta variant has taken hold.

Covid was the leading cause of line-of-duty deaths last year, killing at least 182 officers, according to the National Law Enforcement Memorial Fund, which tracks such deaths. That’s nearly double the number killed by gun violence and vehicle crashes combined. At least 133 officers have died of covid so far this year, according to the organization.

But despite the toll the pandemic has taken, tensions over vaccinations have only increased as unions and individual officers and firefighters have railed against mandates, filing lawsuits and threatening to quit if the shots are required.

Pfizer, partnering with BioNTech, and Moderna has created effective coronavirus vaccines that scientists hope will lead to medical breakthroughs using mRNA. (Joshua Carroll, Brian Monroe/The Washington Post)

When Chicago Mayor Lori Lightfoot (D) announced that all city employees would have to be vaccinated by Oct. 15, the head of the city’s largest police union compared it to the Holocaust.

“We’re in America, G------n it. We don’t want to be forced to do anything. Period,” FOP President John Catanzara told the Chicago Sun-Times. “This ain’t Nazi f---ing Germany, [where they say], ‘Step into the f---ing showers. The pills won’t hurt you.’” he said.

Catanzara later posted a video apologizing for the comments, which were condemned by the mayor and Jewish leaders.

The Los Angeles County Health Department identified hundreds of coronavirus outbreaks at police and fire agencies across the county, according to records obtained by the Los Angeles Times. The outbreaks accounted for more than 2,500 cases — more than half of which were in the Los Angeles Police Department and Los Angeles Fire Department, the paper reported. The fire department said recently that more than half its sworn members have been fully vaccinated, while police chief Michel Moore reported this week that more than 60 percent of his agency’s 12,000 employees — sworn officers and civilians — are fully vaccinated.

Yet employees of both departments have been fierce critics of vaccine requirements and have filed lawsuits in response to a mandate that all municipal employees be vaccinated by Oct. 5, unless they have a medical or religious exemption. Thousands of police employees have indicated they will seek such exemptions.

While there has been much national debate over vaccine mandates in the workplace, experts say first responders are a special case because of the unique position they hold in American life.

Officers wield significant authority, and many of the public’s interactions with police are initiated by officers or by 911 calls summoning them, with people having no choice about whether to engage.

“Somebody gets stopped at a traffic light for a traffic violation, the window goes down, the officer leans toward the person … if they go to a house where there’s been a complaint, they go into the house,” said Jack Greene, professor emeritus of criminology and criminal justice at Northeastern University. “They’re always going into public spaces.”

When police knock on someone’s door, “more often than not, people accede to that request,” said Greene, who has consulted for police departments. “And if they don’t, the door might get broken down. It really boggles the imagination” that any first responder could respond to a call and potentially expose someone else to the virus, he said.

“At the risk of sounding a little bit snide, maybe we should take protect and serve off the sides of patrol cars and put down show up and infect,” he said.

They’re called mild cases. But people with breakthrough covid can still feel pretty sick.

Experts were split about the reasons behind so many officers remaining resistant to vaccination. Some point to the same misinformation and fear impacting the decisions of other Americans.

“Police officers are no different than other people in their community,” said Pasco, with the FOP. He said his initial surprise that police did not flock to the vaccines in larger numbers faded as he saw how fractured the general public was on the topic.

“I’m better informed today as to the depths of divisions on this issue than I was when vaccines first became available,” Pasco said. “The country has not embraced vaccines to the degree that most people anticipated.”

West Virginia was an early leader in covid-19 vaccinations, but health officials say they have hit a wall of vaccine resistance and misinformation. (Jorge Ribas/The Washington Post)

In a recent policy statement, Pasco’s group reiterated its support for vaccinations and said “whether or not to accept the vaccine is a personal decision” up to individual members.

Chuck Wexler, executive director of the Police Executive Research Forum, who frequently speaks to police chiefs, said it appeared to be “predominantly younger officers who do not want to get vaccinated.”

Wexler called the trend “puzzling,” saying he couldn’t explain it.

Charleston police Lt. Robert Gamard reported that some of his department’s officers have said they were still “meaning to do it,” while others remain adamantly opposed. There is no vaccine mandate, he said, but the department has been pushing information to its officers and is exploring making vaccinations available during roll call.

“We’re going to keep trying,” said Gamard, who oversees training for the force.

David J. Thomas, a professor at Florida Gulf Coast University and a retired police officer, described policing as “very conservative in nature.” He noted that in the past, officers have resisted other measures meant to protect them, such as body armor, and are hesitant to adapt to changes.

Officers have the “belief that it’s just not going to happen to them,” he said. Thomas said one police chief told him, “We’ve done everything we can to get them vaccinated, and they won’t listen.”

Thomas said he also believed some officers are vaccinated but not admitting it, comparing it to the work he does with law enforcement on mental health issues. Some officers are hesitant to admit they need help, fearful of seeming weak, and admitting they are vaccinated might be similar, he said.

But as the delta variant-fueled virus surge continues to sweep the country, the prospect of significant numbers of first responders falling ill raises other issues.

“I’m going to use a term the Pentagon would use: It’s a matter of force readiness,” said Sandra C. Quinn, a professor at the University of Maryland School of Public Health. “Will they have a healthy workforce that’s vital for protecting public safety and well-being?”

A vaccine mandate fractures a state fair, leaving children as ‘pawns’

Miami police chief Art Acevedo said he found officers’ resistance to vaccination “very surprising” and “disappointing.”

Acevedo has been an outspoken advocate for vaccinations, and when he signaled support for a mandate last month, local and national police groups lashed out. Pasco called it “management by tantrum,” while the local police union’s president in a letter called the chief’s comments “flat out demoralizing.”

After the pushback, Acevedo, who was chief in Houston before becoming the Miami department’s leader in April, was undeterred, saying unions arguing against mandates were practicing “labor leadership by hypocrisy” after demanding more protective equipment for officers early in the pandemic.

“We need to do everything we can to keep each other alive,” Acevedo said in an interview. “And the one thing when it comes to covid that we know, that the data shows, that’ll help you stay alive … is being vaccinated.”

However, Charlotte-Mecklenburg police chief Johnny Jennings said while he believes in vaccination, he does not support a mandate. Jennings said he preferred to “continue to educate and get cooperation from people to go and voluntarily get vaccinated.”

He noted that the pandemic has “been devastating” for police.

“We don't have the luxury of putting … Plexiglass between us and the people we come in contact with,” Jennings said. He said police “have to be responsible to protect ourselves.”

Yolian Y. Ortiz, a spokeswoman for the FOP lodge representing officers in Charlotte, similarly backed vaccinations while pushing against any requirement.

“We are asking everybody to get vaccinated,” she said. “But we believe it’s a personal choice and should not be mandated.”

Officers, she said, are going through the same thought process as others who have not gotten the shots.

“You want your employees to be able to exercise that personal choice, like religion or your freedom of speech. You don’t want that to be infringed upon,” Ortiz said.

Some departments have been able to obtain high compliance without mandates. Ian Adams, a former police officer in Utah who is a doctoral candidate at the University of Utah, studied police vaccination rates in Salt Lake City and found that most of the department’s officers were vaccinated in a matter of days. Adams said the department’s leadership helped fuel the outcome. (A spokesman for the department said the police chief was not available for an interview.)

“My question for people talking about mandates, is there an alternative to consider? It requires a lot of leadership and hard work and transparency, but none of that’s impossible,” said Adams, who also is also executive director of the Utah State Fraternal Order of Police. “And I think that’s what this case demonstrated.”

Exactly how many officers nationwide are vaccinated is unknown. There are more than 15,000 local police departments in the United States, each with its own policies, and no government agency tracking the information.

The Washington Post requested vaccination rates and policies from dozens of police, fire and city officials. Several said they did not keep track of vaccination rates or had incomplete statistics, while some departments reported numbers suggesting thousands of their employees remained unvaccinated.

Police officials in Atlanta, Austin, Dallas and San Antonio — cities that are home to some of the country’s largest departments — said they have not kept records of vaccinations among their forces, nor were mandates in place. In Chicago, home to the country’s second-largest local police force, officials have not kept track of how many officers are vaccinated although a mandate for city employees goes into effect later this month.

Four patients, two dialysis machines: Rationing medical care becomes a reality in hospitals overwhelmed with covid patients

Of the major departments that are keeping track, Las Vegas officials said more than half of that city’s force is fully vaccinated. The department also said that vaccinations are required for newly-hired police employees.

There is no mandate for New York City police, the country’s largest local department, which said about 62 percent of its workforce — which includes 36,000 officers as well as 19,000 civilian personnel — had gotten vaccinated as of Sept. 23. By comparison, 74 percent of adults in New York are fully vaccinated, according to city data.

Data reported by fire departments also varied. In Austin, vaccinations are not mandated, but fire officials said that 4 in 5 personnel were vaccinated. Both New York and Los Angeles departments reported that more than half of employees are vaccinated.

In Denver, a vaccine mandate covering government workers — including police, fire and sheriff’s department employees — went into effect at the end of September, and those who refuse risk losing their jobs.

Even without mandates, experts said, first responders have an obligation to get vaccinated to protect the public.

They are in “very public-facing positions, and they really have a responsibility to keep the public safe,” said Racaniello, the Columbia professor.

Friday, October 15, 2021

COVID-19 Vaccine Mandates—A Wider Freedom

Lawrence O. Gostin, JD
Author Affiliations Article Information
JAMA Health Forum. 2021;2(10):e213852. doi:10.1001/jamahealthforum.2021.3852
COVID-19 Resource Center

President Biden has required COVID-19 vaccinations across much of the US workforce, reaching nearly 100 million workers. Opponents call it unconstitutional, a violation of personal freedom, and even “un-American.” The truth is that vaccine mandates are lawful and deeply entrenched in US history and values. They constitute a “wider freedom” so that everyone in society can feel safer where they work, learn, worship, and live.

Vaccine Mandates Integral to US Culture and Tradition

Vaccine mandates are very much part of US culture and tradition dating back to the colonial era, even before Edward Jenner’s 1796 discovery of cowpox vaccinia. George Washington required smallpox inoculations for the Continental Army in 1777, writing that “we should have more to dread from [smallpox], than from the sword of the enemy.” He condemned a Virginia law restricting inoculations, saying he would rather move for a law to compel inoculation of all children “under severe penalties.” Massachusetts enacted the first law mandating immunization in 1809, and by the time the US Supreme Court upheld its constitutionality in Jacobson v Massachusetts (1905), municipal and state smallpox vaccination mandates were prevalent across the US.

States began requiring childhood vaccinations as a condition of school entry by the mid-19th century and by 1963, 20 states had school vaccine mandates. Although the US Centers for Disease Control and Prevention (CDC) has a recommended schedule for child and adolescent immunization, it does not set vaccination requirements for schools. The CDC points out that each state makes its own decisions about which vaccines are required for school attendance in that state. All school immunization laws grant medical exemptions, 44 states grant religious exemptions, and 15 states allow philosophical exemptions. Although vaccines are not routinely required for adults in most settings, they are often mandated for military service members, new immigrants seeking permanent US residence, college and university students, and health care workers. Previous epidemics like the 2018-2019 measles outbreak in New York City were quashed by emergency vaccine mandates for adults in affected zones. Even before President Biden’s COVID-19 vaccine mandate announcement, several cities and states, businesses, and institutions of higher education had issued their own COVID-19 vaccine mandates.1

COVID-19 vaccine mandates, therefore, should not be viewed as an aberration but as the continuation of a long tradition in the US to prevent or mitigate infectious disease outbreaks and epidemics. The CDC recognizes vaccinations as among the top public health achievements of the 20th century.

Vaccine Mandates Lawful

Cities and states have broad “police powers” to require vaccinations, upheld twice by the US Supreme Court in 1905 and 1922. The Pfizer-BioNTech COVID-19 vaccine is fully licensed for individuals aged 16 years or older and has received Emergency Use Authorization for children aged 12 to 15 years. (It is likely that vaccines will soon be authorized for children aged ≥5 years.) The police powers of cities and states enable them to require eligible individuals to be vaccinated against SARS-CoV-2 for school attendance, as the Los Angeles Unified School District recently did covering more than 600 000 students. New York City’s “Key to NYC” program requires proof of COVID-19 vaccination for indoor activities such as dining, fitness, and entertainment. The courts have upheld Jacobson v Massachusetts for more than a century, affording municipalities and states wide discretion in exercising public health powers, including mandatory vaccinations.2

Unlike cities and states, the federal government does not have broad public health powers. The president has only limited public health powers and could not, for example, issue a nationwide vaccine mandate. President Biden’s 3 vaccine requirements, however, have strong legal support. First, President Biden ordered all federal workers and contractors to be vaccinated. There is no option to be tested for COVID-19 instead of being vaccinated. As head of the federal workforce, Biden has the power to set evidence-based safety standards, including mandating masks and vaccines. The Equal Employment Opportunity Commission and the Department of Justice both advised that governments and businesses can require COVID-19 vaccines as a condition of employment, so long as they provide religious and medical exemptions. Courts also have upheld COVID-19 vaccine mandates for employees as well as college students.

Second, President Biden ordered all health care facilities to require COVID-19 vaccinations as a condition of receiving certain Medicaid or Medicare funding. The Supreme Court has ruled that the federal government can set reasonable conditions for the receipt of federal funds. In South Dakota v Dole (1987), the Supreme Court upheld a law requiring states to adopt a minimum drinking age of 21 years as a condition of receiving certain federal highway funds. So-called conditional spending must be reasonable. For example, the Supreme Court struck down a requirement in the Affordable Care Act for states to expand Medicaid as a condition of receiving all Medicaid funding, ruling that the amount of funding at stake made the contingency unduly coercive.

President Biden’s third, and most controversial, vaccine mandate requires businesses with 100 or more employees to either mandate COVID-19 vaccinations or institute weekly testing and other risk mitigation measures. Opponents have called it an “overreach” and unconstitutional, but President Biden is acting at the height of his presidential powers. He is not making a unilateral executive decision but is rather acting through specific congressional authorization. In 1970, Congress enacted the Occupational Safety and Health Act precisely because of a weak patchwork of state worker safety regulations. It empowered the Department of Labor to set uniform national workplace safety standards, including emergency temporary standards in response to workplace hazards. Exposure to SARS-CoV-2 can be just as hazardous as workplace injury risks. The Occupational Safety and Health Administration (OSHA) has already set emergency temporary standards for COVID-19 exposures in health care settings. Previously, OSHA set bloodborne pathogen standards that included hepatitis B vaccinations. OSHA is currently devising emergency temporary standards for COVID-19 vaccination or weekly testing, which is expected to be issued soon.

Two Freedoms

Freedom holds deep ethical and legal value in the US. There are at least 2 types of freedom—freedom from personal restraint and a wider freedom to engage in daily life without significant risk of exposure to safety hazards. Vaccine mandates are justified under both notions of freedom. Certainly, competent adults have the right to bodily integrity and to make their own health care decisions. Yet, the right of informed consent has clear limits. No one has the right to expose others to a potentially serious infectious disease. Even though breakthrough SARS-CoV-2 infections after vaccination do occur, vaccinated individuals pose transmission risks for much shorter periods compared with unvaccinated individuals. Thus, a fully vaccinated workforce, especially if layered with other risk mitigation measures such as wearing a mask and improved ventilation, creates a far safer environment for everyone.

In his annual address to Congress in 1941, Franklin D. Roosevelt identified “Four Freedoms”—for speech and worship, as well as freedom from want and from fear. By freedom from fear, he meant that the public has the right to engage in daily social and economic life without fear of avoidable harms. It is unknown how much COVID-19 vaccination coverage is needed to contain SARS-CoV-2, but it probably requires rates exceeding 80% of the population. It is important to remember that everyone in society is interconnected. Our individual choice to not get vaccinated poses avoidable risks to the people we interact with and those with whom they interact. The higher the vaccination coverage, the safer we all are.

Highly vaccinated populations create a wider freedom to return more safely to the ordinary activities people value—such as going to work, school, cafés or restaurants, the theater, or sporting events, as well as traveling. COVID-19 vaccines are a remarkable scientific tool that enables society to live in greater freedom and with less fear. Using every tool—including mandates—to achieve high vaccination coverage enhances freedom.
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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Gostin LO. JAMA Health Forum.

Corresponding Author: Lawrence O. Gostin, JD, Georgetown University Law Center, 600 New Jersey Ave NW, Washington, DC 20001 (

Conflict of Interest Disclosures: None reported.
Gostin LO, Shaw J, Salmon DA. Mandatory SARS-CoV-2 vaccinations in K-12 schools, colleges/universities, and businesses.  JAMA. 2021;326(1):25-26. doi:10.1001/jama.2021.9342
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Gostin LO. Jacobson v Massachusetts at 100 years: police power and civil liberties in tension.  Am J Public Health. 2005;95(4):576-581. doi:10.2105/AJPH.2004.055152PubMedGoogle ScholarCrossref

Wednesday, October 13, 2021

The Right Answer and the Effective Answer

The comment below was written by an orthopedic surgeon in response to this article

October 8, 2021

Steven Zeitzew, M.D. | West Los Angeles VA Healthcare Center
There is a large difference between being correct and being effective. As an orthopaedic surgeon I learned long ago that telling patients what to do is less effective than informing them effectively about the consequences of the choices before them, and gently guiding them so they can make the correct choice willingly. Sometimes mandates are effective and necessary, such as vaccines for schoolchildren or for healthcare workers in at least some circumstances. What we are learning is that telling people we are forcing them to do the right thing is sometimes not an effective technique for getting them to actually do the right thing. Sometimes telling a "biker dude" that he cannot put weight on his leg after fracture surgery won't work, because he won't do something just because he is instructed to, and is in fact more likely to do the opposite. That same patient is smart enough to make a good decision if he is informed of the poor prognosis associated with excessive premature weight-bearing before fracture healing. That is human nature. We don't like being told what to do. We do like making well-informed decisions on our own. Even a well-intended mandate based on the best evidence will sometimes be a less effective technique for getting people to make the right choice.

It might be more effective to provide reliable information and allow patients to decide about vaccination on their own in many circumstances, even though some will make the poor choice of declining vaccination, in spite of the overwhelming and persuasive evidence supporting COVID vaccination. Liberty and freedom are important to human beings, and threatening to take it away will have consequences. We will find we cannot force all people to do the right thing. We will also find that most people will make the choice to do the right thing when they are allowed to give informed consent, the same standard we use for other medical interventions, even when they face a life and death choice that affects them and those around them. Yes, sometimes we must impose a choice in order to protect others. Forcing our choice may not be the most effective technique in this instance.

Thursday, October 7, 2021

In case you're in Irving and or headed here....

Captain Jeff Wright secured the funding and filed the mandatory Certificate of Insurance (COI), the course for event number 518 was set up and ready to go. 

Then the DFW fire marshals descended with the grim news. The event cannot be held on an empty parking lot that can accommodate a 747. They delivered the news after the close of business sending us into General Quarters status with an after-hours search for Plan B.

As we packed up under the dark sky, we secured an alternative location: The Irving Mall. 

So, we'll take the tower down first thing tomorrow and the show will go on at 4p CDT. 6.7 miles away

See you there: