Check out my newest publication, “Choosing a New Path: How My Diagnosis with Bipolar Helped Me Build A Better Life” published in the award-winning blog, The Bipolar Battle. Here’s the link:

https://www.thebipolarbattle.com/choosing-a-new-path-how-my-diagnosis-with-bipolar-helped-me-build-a-better-life/

Podcast to follow!

1. Roll of Thunder Hear My Cry by Mildred D. Taylor

This is the first book that I can remember reading that was written by a non-white author. It was one of my favorite books growing up. It started the process of opening my eyes to the racism that is still rampant in our country. Set during Jim Crow, I remember being horrified that [white] people could treat others so horribly. I identified strongly with Cassie and remember crying on several occasions while reading this book. I read this book so many times the spine fell apart, so I don’t own a copy anymore. Interestingly, this book was banned in the 1990s and early 2000s because of ‘racial bias’ and racial epithets.  

2. I Know Why the Caged Bird Sings by Maya Angelou

I was nine years old, reading this book on the top bunk of my bed while my mom folded laundry in the next room, when I called out, “Mom, what’s rape?” She suddenly got very quiet. She checked to see what I was reading, and then we had a long talk. But what really stuck with me about this book was Maya’s spirit, her unwillingness to let her negative experiences define her. This book was also my first introduction to poetry, and Caged Bird remains to this day one of my all-time favorite poems. 

3. A Long Way Gone: Memoirs of a Boy Soldier by Ishmael Beah.

I read this book before my trip to Sierra Leone. Reading about the civil war in Sierra Leone and the horrors of child-soldiers gave me a frame of reference for the people and places I saw during the month I spent in that beautiful country. Reading this book helped to prepare me for the many difficult conversations and situations that cropped up along the way. On an uplifting note, we went to the town the author came from and happened to meet his grandmother. One of us had the book with us, and we showed it to her. She started crying when she recognized his face on the back cover: she hadn’t known he was still alive. We offered to try and connect with him once we got back to the US, but she insisted that just knowing he was alive was enough. That moment has stayed with me for a long time. 

4. Inheritance Trilogy by N.K. Jemisin

The Inheritance Trilogy more than a gripping series that I couldn’t put down. It reminded me that not all fantasy needs to be western-centric, white-centric, or hetero-centric. Her gender-fluid, poly-amorous gods are a potent reminder that there’s a reason we need BIPOC LQBTQA authors in all genres.  

5. Becoming by Michelle Obama

I couldn’t stop quoting this book for months after I read it. So many poignant moments, so many incredible insights into what it means to be an American, especially a black American. After reading this book, I felt like I understood Michelle (and Barack) on a deep, personal level, which only increased my respect for them. I don’t read a lot of biographies, but this one was so full of truth and joy and personality that I couldn’t put it down.

6. Friday Black by Nana Kwame Adjei-Brehnyah

This collection contains some of the most powerful short stories I have ever read. When we started the audiobook, my husband and I listened to the entirety “The Finkelstein Five” in total silence, completely absorbed. When it ended, we just sat in our shock. It was so beautifully written, so gut-wrenching that we were both moved to tears. I’m still working my way through the book (we listen to it on long car-rides, and since COVID, there haven’t been a lot of those), but those first few stories were so powerful it deserves a place on this list.

7. The Murmur of Bees by Sofia Segovia

One day, I hope to read this book in its original Spanish. The magical realism in this book is incredible. I love reading historical fiction and adore fantasy, but this was the first book I ever read that so beautifully blended the two. This book was an inspiration for several of my short stories.

8. Invisible Man by Ralph Ellison

I read this book in high school and it was one of those books that I read really slowly. Not because it was boring, but because there was so much to think through. It was my first adult(ish) experience learning about the social invisibility of black people in our country, and it left a mark. 

9. Better by Atul Gawande

This book made me so excited and proud to be a doctor. I read it during my first year of medical school and it lit a fire under me. I wanted to be an Ob/Gyn physician and to make a difference for my patients by ‘counting’ and noticing things others did not. Life didn’t turn out that way, but his words still ring true in my life as a writer.

10. The Paper Menagerie by Ken Liu.

I was introduced to the works of Ken Liu through the animated short “Good Hunting,” in the Netflix series Love, Death, Robots. I was so excited to learn that he has several collections of short stories and I couldn’t wait to read them and I wasn’t disappointed.  The Paper Menagerie is so much fun! The writing is beautiful, creative and absolutely fascinating. Studying his works has helped me to become a better writer.

Bounus: Books I thought were by BIPOC authors but are not.

Walk Two Moons by Sharon Creech

Bury My Heart At Wounded Knee by Dee Brown

The Girl Who Loved Wild Horses by Paul Goble

Apparently, all my favorite books about Native Americans are not actually by Native Americans! I need to work on this. Comment if you have a suggestion for the next book by a BIPOC author that will rock my world!

Part I: Healthcare

If you’re like me, you’re probably stuck at home feeling rather anxious and more than a bit helpless. The good news is: there are lots of ways we can help! I’ve interviewed healthcare providers and asked what they need at the front lines. Here are some of their answers.

Donate Any Personal Protective Equipment (PPE)

By now, everyone knows that we are quickly running out of Personal Protective equipment (PPE). Doctors, nurses, paramedics and lab techs do not have enough respirators, gloves, gowns and masks to perform their daily tasks safely. Providers are being told to reuse their masks (which are normally disposable after one use) until they ‘fall apart,’ or told they are not allowed to wear a mask unless they are within two feet of a potentially infectious patient.   

PPE, such as gloves, masks, respirators, hand sanitizer, gowns, or face masks, are in dire need by healthcare providers. You do not need need PPE for a regular trip to the grocery store or pharmacy, unless you are actively sick (in which case, you should just stay home anyway). Yes, certain countries such as China, Taiwan, and South Korea, have shown that if the general population wears masks when they go out, it can help flatten the curve. But they are not facing the huge shortage of PPE that we are. When it comes down to it, our healthcare providers are on the front lines, interacting with COVID patients every day. If we want our healthcare providers to keep showing up to work, then we need to do our best to make sure they are protected.

You are not alone if you have stockpiled masks. Apple recently donated 9 million masks, with Facebook and Goldman Sachs following suit. Even if you just have one or two items, a small donation can make all the difference. If you live in Oregon, you can drop off donated PPE here. If you live anywhere else in the US, check out this website for more details.

Stop making fabric masks

Yes, you heard me. Please stop. They can actually make things worse. N-95 respirators are made from an extremely dense fabric that filters out 98% of the particulates from the air. Fabric masks only filter about 3%. The CDC has put out guidelines that medical professionals should wrap a scarf or bandanna around their face if, and only if, there is absolutely no other protective option. Ideally, it should be paired with a face shield. While this is kind of like asking soldiers to go to the front lines with a vest that is 3% bullet-proof, it is a measure of how desperate the situation is.

But isn’t a cloth facemask better than nothing? No! First, you have to get the material for the masks somewhere and going out to buy supplies is taking an unnecessary risk, putting yourself and the retail workers in danger. Second, fabric masks provide a false sense of confidence. Due to the familiarity of the mask’s feel and presence, the mask may cause providers to take unsafe risks. Research has shown that there are fewer accidents when safety markings are removed from the road (for instance, the white line in the middle) because people drive more carefully when there is uncertainty. In other words, a false sense of security is actually more dangerous than minimal safety features. Finally, and most importantly, a recent study published in the British Medical Journal Open found that the rates of respiratory infections are higher in healthcare providers wearing fabric masks. 

“Cloth masks should not be used by workers in any healthcare setting, but particularly high-risk situations such as emergency departments, intensive care, paediatric or respiratory wards.”

BMJ Open

Hold up. Aren’t hospitals asking for donation of masks? Why yes, they are. This is a source of friction for many physicians. The promotion of fabric masks has mostly been through hospital administrators and fabric manufacturers, rather than through solid medical advice and evidence.

If you have already made fabric masks, the best use would be for you! No, that’s not a contradiction of everything I’ve already said. Fabric masks are not very good at filtering out particulates, which is why they are bad for healthcare providers directly in contact with virus-shedding patients. But you are much less likely to come into direct contact with a COVID-19 patient, and fabric masks can help prevent you from spreading germs to others. Since approximately 80% of COVID infections are mild or asymptomatic, there’s a chance you have it and don’t know it. So, if you’ve made fabric masks, wear it yourself when you go out in public, just as an added layer of precaution. Again, don’t make a special trip to buy material; the best thing to do is just stay home. 

Give Blood!

Currently, the American Red Cross cites a critical need for blood and platelets. If you have never donated, or if you haven’t donated in a while, now is the time! Blood drives are being cancelled at an alarming rate, but the need for blood is the same. Unfortunately, even in the time of COVID, people still get in car wrecks, have cancer, or need emergency surgeries. Without enough blood donations, we could have a secondary healthcare crisis on our hands. If you’re interested in finding out where to donate blood, you can find donation sites through the Red Cross or NW Bloodworks.

If you’re going to make your own hand sanitizer…

The CDC is pretty clear on this: hand washing with soap and water is always better. Store-bought hand sanitizer should be used only when you don’t have access to soap and water, such as at the grocery store or pharmacy. And yes, all hand sanitizer has apparently disappeared from the face of the earth. (Although a bunch of distilleries have banded together to make more! Read the story here)

If you’re going to make your own, you need at least 60% alcohol, and a moisturizing ingredient to make sure you’re hands don’t become cracked and raw (and thus easier for viruses and bacteria to grow). This means using rubbing alcohol and aloe vera. No, vodka isn’t strong enough, and ‘naturally occurring’ essential oils such as vitamin E or witch hazel do not kill the virus. A recipe can be found here.

However, homemade hand sanitizer should only be used in extreme situations, where no handwashing will be available for the foreseeable future. Hand washing actually kills and physically removes germs, but hand sanitizer only reduces their numbers. So wash those paws!

Take Care of Yourself

COVID-19 isn’t the only disease out there. You don’t want to be one of those people getting rushed to an already overwhelmed ER. Obviously, many emergencies can’t be helped, but don’t go to the ER unless it’s a real emergency (I’m looking at you, my 2am toe-fungus patient!). If you have a chronic disease or take medications, check your supply and make sure you have refills. Contact your provider well in advance if you need more.

Taking care of yourself isn’t just a good idea; it can go a long way towards relieving the stress on the healthcare system by preventing sick visits. Drink lots of water, eat healthy, go outside and exercise if you can. In these times of stress and isolation, it is also important to take care of your mental health, whether that’s taking your meds, journaling, art, prayer, music, meditation or watching terrible Disney sequels (guilty). Reach out to the people you love – phone calls, Facetime, Zoom, email, handwritten letters – you name it. Social distancing does not mean emotional distancing.  

Stay Home

It isn’t sexy or particularly interesting, but the best thing we can do right now is to shelter in place. You know the rules. Stay home except for necessary chores (grocery store, pharmacy, etc), cancel all social gatherings and playdates, don’t visit your Grandma, stay six feet apart when in public, and Wash. Your. Hands.

Of note, social distancing does not mean stay indoors. You can go for a run, take your dog or kids for a walk around the neighborhood. But don’t drive out to the beach for the day. Don’t attempt to hike Multnomah Falls or Dog Mountain. If its outside, but there’s a crowd, it is not social distancing. Use common sense.

I’ll talk about that more in my next post, ‘How to help Part II: Community.’ For now, I hope these suggestions are helpful. Leave a comment with any questions or suggestions!

As many of us now have extra time on our hands, I thought I would offer up some book suggestions, organized by mood.

Mood: Heart-pumping adventure set in post-viral apocalypse…Try “A Boy and His Dog at the End of the World” by C.A. Fletcher

When the family dog is stolen, young Griz must set out across an empty world to bring her back.  Entirely compelling, this book is a tale of survival, hope, love, companionship, and loyalty.

Mood: Whimsical family character drama…Try “My Grandmother Asked Me To Tell You She’s Sorry” by Frederik Backman

This book made me laugh. It made me cry. The characters in this story are so quirky you can’t help but love them. The story is simple: a little girl delivering messages for her grandmother. But the pure imagination, the interweaving of B-stories, and the beautiful frailty of the characters are the best reasons I can give to read this book.

Mood: Enveloping Fantasy…Try “The Name of the Wind” by Patrick Rothfuss

If you’re a big fantasy fan, you’ve probably read the King Killer Chronicles at least twice. Like me, you’re probably twisting in agony waiting for the third book to finally come out. But if you don’t usually read or enjoy fantasy, I would recommend you try this book anyway. It is beautifully written. Every sentence is crafted. At one point, you meet a character similar to Titania from Midsummer Nights Dream and she speaks in iambic pentameter. I couldn’t make this up if I tried.  The characters are at once incredibly endearing and deeply flawed. The magic system is unique, intricate, and incredibly difficult. I love this book, as well as its sequel, “The Wise Man’s Fear.”

Mood: Pure poetry…in novel form…Try “This is How You Lose the Time War” by El Motar Amal and Max Gladstone

Queer “Romeo and Juliette” meets “Terminator” meets time travel. Not exactly the description you would expect under the heading of ‘Pure Poetry,’ but this is one of the most beautiful books I have ever read. The plot is simple – the passing of messages – but the ingenuity, creativity, and sheer beauty of the prose and storyline is what makes this short novel truly special.       

Mood: Nostalgia… Try “Becoming” by Michelle Obama

Dreaming of a time when America had a sure-footed and dependable leader? Mrs. Obama’s memoir is funny and insightful, and her prose has a way of making me feel like everything is going to be all right after all.

Mood: Restore your faith in humanity Try “All the Light We Cannot See” by Anthony Doerr

Set in Paris and Germany, this stunning novel follows the paths of a blind French girl and a poor German boy as the second world war ramps up. Poignant, heartbreaking and pitted with beautiful moments of kindness, it is ultimately a story about why people need to be good to each other.

Mood: Light and fluffy….try “Someday, Someday Maybe” by Lauren Graham

Written by Gilmore Girls and Parenthood star, Lauren Graham (and performed by her on the audiobook), this story is about a young woman trying to make it as an actress in NYC. The plot is about as cliché as it gets, but it is charming and often laugh-out-loud hilarious. If you’re looking for high literature, maybe pass this one by. But if you’re looking for a laugh and a heroine who makes you feel pretty good about yourself, this might be the book for you.

Mood: Uplifting non-fiction… try “The Rainbow Troops” by Andrea Hirata

Set on the Indonesian island of Belitong, the Rainbow Troops is a story about eleven desperately poor children and their quest for an education. Assisted by two marvelously dedicated teachers, these students fight tooth and nail to save their school from bureaucrats, weather, mining – you name it. The audacity and strength of the students and teachers is inspirational. But Mr. Hirata does not gloss over the realities of life on their island, and the glaring inequities can be enough to break your heart. 

Mood: Educational non-fiction… try “A Grown-ups Guide to Dinosaurs” by Ben Garrod

Were you obsessed with dinosaurs as a kid, but have since forgotten the difference between an Apatosaurus and a Brachioaurus? Me too! This book taught me more about dinosaurs than I ever knew I’d forgotten. Hilarious and well-researched, this short book is a great read for anyone who wants to be constantly reminding their friends that dinosaurs walk among us.

Mood: A thriller that doesn’t make me want to throw it against the wall… try “The Family Upstairs” by Lisa Jewell

I’ve read a lot of bad thrillers. Unrealistic heroines, plot holes the size of a school bus, ‘surprising’ twists that I was pretty sure were going to happen since chapter 3. But this isn’t one of them. Perhaps it’s because the murder-mystery isn’t actually the most important aspect of the book. It’s about character. A young woman finds out she has inherited a mansion. A middle-aged mother living on the streets tries to find her way back to London. A young boy watches as his home becomes the center of a cult. These three storylines are woven together beautifully, and though there’s no real “gotcha” moment, it’s very satisfying when all the pieces fall into place.

Mood: Non-Western Historical Fiction… try “Pachinko” by Min Jin Lee.

Beginning in the early 1900s, the novel follows a Korean family through several generations as they emigrate to Japan, survive both World Wars, and try to make a better life for their children. It is a story of love and sacrifice, ambition, and loyalty. I learned a lot of Korean history from this book, including the treatment of Koreans living in Japan.

Mood: I want to chew on an idea … try “That Kind of Mother” by Rumaan Alam

This book is all about ideas. It’s about motherhood, in all its unique forms. It’s about the trials of breastfeeding, the social isolation of having a newborn. It’s about transracial adoption and all the pitfalls of a suburban white woman raising a black child. I have read a lot of books dealing with adoption (my little sister is adopted, so it’s a topic close to my heart), and white adoptive mothers are usually cast as selfless angels or self-absorbed women of privilege with no real connection to their child. Instead, Rebecca Stone is a fully-fledged, multidimensional character, with good intentions, powerful desires, and huge blind spots that cause her to stumble. If you are looking for a book with a lot of action, this is not the book for you. If you want a deep dive into motherhood and the perils and joys of transracial adoption, I can’t recommend this book more fully.

And yes. Rumaan Alam is a gay black man. To me, that just makes the beauty, depth, and intimacy of this portrait of a suburban white mother even more impressive.  

Thanks for reading. Hope you enjoy!

One of the most common concerns about the implementation of a universal healthcare system, sometimes called Medicare for All, is that wait times will increase drastically under a government-run system. The President himself has made many comments to this effect, including on the White House website, stating that “Medicare-for-All would force patients to face massive wait times for treatments and destroy access to quality care.” Anecdotes abound on both sides of the issue: Canadians waiting months in agonizing pain for a hip replacement, a young American man dies because he can’t afford his insulin. But what is truth and what is fiction?

Universal Healthcare Around the World

Universal Healthcare is defined by the WHO as a healthcare system in which all citizens are guaranteed access to healthcare without risk of financial hardship. Since 1948, it has been considered by the UN to be an essential human right. There are over 100 countries in the world with policies for universal healthcare, thought the Organization for Economic Cooperation and Development (OECD) recognizes only 18 that have achieved true, 100% coverage: Australia, Canada, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, the Netherlands, New Zealand, Norway, Portugal, the Slovak Republic, Slovenia, Sweden, Switzerland and the United Kingdom. But Universal Healthcare is not a catch-all diagnosis. Every country’s policies are different, tailored to that country’s values and population. But it is possible to sort them into three general categories.

The first and best-known model is the single-payer system. Funded by taxes, a local, regional or national health system provides all healthcare to the population in countries like the United Kingdom, New Zealand and Sweden.  This system is most comparable (though not identical to) to the ‘Medicare for All’ plan proposed by Democratic Presidential candidate, Bernie Sanders. But this is not the only path to Universal Healthcare. The Netherlands and Switzerland utilize a regulated healthcare market, also known as Social Health Insurance. Like the Affordable Care Act, or ‘Obamacare,’ this model requires everyone to buy private health insurance, but controls insurance prices through the government. Finally, a National Health Insurance plan utilizes a public insurance system to pay for private healthcare services. Utilized in Canada and Germany, this system is the model for the current Medicare system in the USA. According to a recent study by the CommonWealth Fund, private health insurance can be incorporated into all of these models, and that many countries utilize a mixture of healthcare systems. Australia for instance utilizes a single-payer system, but allows those who can afford it to purchase private insurance to ensure higher quality and faster care. The wide variety of different healthcare systems makes direct comparisons difficult, but it is important to first understand where we, as Americans, fit into this system.       

Compared to the USA

The United States spends more on healthcare than any other country in the world, but this doesn’t mean Americans are any healthier. Utilizing a mix of private and public insurance, 67% of Americans receive insurance through the private sector, mainly their employer, according to the US Census Bureau. 37% who receive government insurance through Medicare, Medicaid, military or other government services. However 9% of Americans, over 44 million people, have no health coverage at all. Of those with insurance, an estimated 38 million are underinsured, meaning that they have high-deductible or coinsurance plans which cause them to struggle with payments or skip treatment altogether. This creates a two-tiered system, in which those who can afford insurance enjoy access to high-quality private healthcare, while those without are forced to do without.    

Wait Times

Average wait times are broad indicators of the quality of a healthcare system. It can include wait times to see Primary Care Physicians (PCPs), time to imaging, or even time to an elective procedure. A 2017 study utilized wait times as one of more than 70 indicators of healthcare performance, comparing the US to ten other countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. In this study, the US ranked dead last in access to medical care, equity and healthcare outcomes. On measures of timeliness, it ranked third to last, behind Canada and Sweden. On some indicators, however, the US did quite well. It ranked 4^th for fewest patients waiting more than 2 hours in the emergency room; 2^nd for fewest patients waiting 2 or more months to see a specialist; and tied for 3^rd for fewest patients waiting 4 or more months for an elective surgery. However, it did terribly on several other measures, ranking in the bottom third for patients having access to a regular doctor, after-hours or same-day care, and specialized tests such as CT or MRI. In terms of overall timeliness, the US ranked 8^th out of 11. Canada received last place by a large margin, due to long wait times for elective surgery and specialist appointments. However once affordability was considered, the US pretty much dropped out of the race.

With an appallingly high percentage of people unable to pay a medical bill, being denied insurance reimbursement, or simply skipping treatment due to inability to pay, the United States scored dead last in the category of affordability. In other words, many Americans are simply unable to afford healthcare. This two-tiered system means that people who can afford high quality health insurance enjoy slightly better than average access to elective procedures and specialists, while those of lesser means may not be able to access healthcare at all. Finally, it is important to note that that increased access for some did not result in better outcomes. The US also ranked last in terms of health outcomes, in categories such as infant and maternal mortality, chronic conditions, mortality amenable to healthcare, 5-year colon cancer survival and life expectancy after age sixty, among others.  In other words, slightly better wait times did not improve overall outcomes.   

Conclusion

When it comes to wait times in the American Healthcare system, the picture is mixed. Those who can afford it enjoy slightly better than average wait times when it comes to scheduling elective procedures or appointments with specialists. But wait times to see a PCP or receive specialty testing are much longer. These averages do not take into account the 82 million people who are uninsured or underinsured. For them, the wait may be indefinite.

For those concerned about wait times associated with universal healthcare, it is important to understand that the United States is neither the best nor the worst. Countries with universal healthcare like France and Germany have shorter wait times for elective surgeries and specialist appointments, while in Canada and New Zealand the wait is longer. Every country has their own system, with the resultant strengths and weaknesses. Would switching to a universal healthcare system mean longer wait times for the average American? Maybe. Maybe not. It depends on the system we choose and the success of its implementation. The real question is: does it matter? As Americans, we are the proud owners of the most expensive, least effective healthcare system in the world. Is a slight increase in wait times worth ensuring that every American has access to the healthcare they need? I certainly believe so. But ultimately, it will be up to voters to decide.

Works Cited

1. “President Donald J. Trump Stands Against the Lies of Medicare-For-None.” The White House, The United States Government, 3 Oct. 2019, www.whitehouse.gov/briefings-statements/president-donald-j-trump-stands-lies-medicare-none/.
2. “Questions and Answers on Universal Health Coverage.” World Health Organization, World Health Organization, 11 June 2013, www.who.int/healthsystems/topics/financing/uhc_qa/en/.
3. Tikkanen, Roosa. “Variations on a Theme: A Look at Universal Health Coverage in Eight Countries.” Commonwealth Fund, Commonwealth Fund, 22 Mar. 2019, www.commonwealthfund.org/blog/2019/universal-health-coverage-eight-countries.
4. Berchick, Edward, et al. “Health Insurance Coverage in the United States: 2017.” The United States Census Bureau, 16 Apr. 2019, www.census.gov/library/publications/2018/demo/p60-264.html.
5. “Underinsured Rate Rose From 2014-2018, With Greatest Growth Among People in Employer Health Plans.” Commonwealth Fund, 7 Feb. 2019, www.commonwealthfund.org/press-release/2019/underinsured-rate-rose-2014-2018-greatest-growth-among-people-employer-health.
6. Ridic, Goran, et al. “Comparisons of Health Care Systems in the United States, Germany and Canada.” Materia Socio Medica, vol. 24, no. 2, 2012, p. 112., doi:10.5455/msm.2012.24.112-120.
7. Doty, Michelle M. Doty, et al. “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care.” The Commonwealth Fund, 2017, doi:10.15868/socialsector.27698.

For the past two weeks, Jada has driven past the same tree nearly every day. It’s several miles out of her way, and not particularly pretty. But it’s close to the road, on a quiet street without sidewalks or a bike lane, and its trunk is strong and broad. So Jada drives past, every day, wondering when she will get up the courage to step on the accelerator and slam her car straight into it.

Jada’s hopelessness, guilt and suicidal ideation aren’t new; she’s been struggling with these feelings since she was a teenager. Misdiagnosed with depression, it took years for Jada’s periods of extreme productivity, feelings of elation or anxiety, and mild insomnia to be diagnosed for what they were: hypomania. When she is finally correctly diagnosed with Bipolar II, she is told that she was lucky to have escaped diagnosis with the more severe version of the disorder, Bipolar I. But as her moods continue rocket back and forth, she wonders how her disease could get any worse  

Overview of Bipolar Disorder

Jada’s story is not unusual. Bipolar Disorder (BD) affects 5.7 million adults in the United States every year; about half of those have Bipolar II¹. A disease of two extremes, Bipolar Disorder is defined by the presence of manic or hypomanic symptoms on one pole, with depression on the other. Mania is an elevated mood state characterized by increased energy, talkativeness, grandiosity, distractibility, and impulsivity, usually combined with decreased need for sleep. The less severe version, hypomania lasts for less than a week and does not impair functionality or necessitate hospitalization. Depression is the opposite pole. Diagnosis requires a depressed mood state characterized by diminished interest, physical slowing, fatigue, changes in sleep and appetite, feelings of guilt and hopelessness, and thoughts of death or suicide.  The diagnosis of Bipolar I requires only a single episode of mania, though most peoples will also experience depressive episodes. But to be diagnosed with Bipolar II, you must have a history of both a Major Depressive and a hypomanic episode.

Mania vs. Hypomania

Because people with Bipolar II never experience full mania, it is sometimes considered a less severe disease. In fact, the diagnosis was not added to the Diagnostic and Statistical Manual of Mental Disorders – the psychiatrist’s primary diagnostic guide – until 1994. In some ways, this is understandable. Mania is, by definition, more severe than hypomania,. It often has severe and far-reaching consequences, including hospitalization, divorce, even financial ruin.

Yet hypomania is still a life-changing condition that needs to be taken seriously. It can be uncomfortable, leading to severe irritability, anxiety or akathisia; a feeling of painful restlessness. It can lead to high risk behaviors, such as substance abuse, dangerous driving and risky sexual practices. Even in its milder, euphoric form, the increased talkativeness, energy and impulsivity can strain relationships to the breaking point. Furthermore, since many people are happy and productive during a hypomanic episode, they are unlikely to bring it to the attention of their physician. This can lead to delayed and missed diagnoses.

Depression & Suicide  

Like Jada, nearly 40% of people with BD are initially diagnosed with Major Depressive Disorder³. While misdiagnosis is common for BD in general, diagnosis of Bipolar II is notoriously challenging. Because hypomania is milder and often does not impair daily life, people like Jada often do not report these symptoms. It can take years before their hypomania is discovered. During this time, they are often mistreated with antidepressants, which can in itself induce mania.

Patients with Bipolar II are also at higher risk of recurrence. They have a higher number of lifetime episodes than those with Bipolar I, and the interval between episodes gets shorter as the patient ages². As much as 20% of people transition directly from one episode to another, with no inter-episode recovery. There is also evidence that they have a higher incidence of mixed features, meaning they experience symptoms of both mania and depression simultaneously. Mixed features are associated with both increased severity and worse prognosis of the disease. It is also associate with a higher risk for suicide.

The lifetime suicide risk in people with BD is more than 20 times that of the general population². Over 1/3 of people with the disorder will attempt suicide at some point in their lives. With 20% lifetime risk of death by suicide, people with Bipolar live an average of 9.8 years less than the general population². In fact, it is believed that BD may account for as much as 25% of all completed suicides. While people with Bipolar I and II have similar rates of suicide attempts (36.2% and 32.4%, respectively), people with Bipolar II have a higher rate of completed suicides. While the exact reason for the increased lethality is unknown, increased time in the depressive state, increased severity of depression, and increased risk of mixed features are all likely contributors.

Long Term Effects

Even between mood episodes, people with Bipolar are affected by the disorder. Cognitive impairment, primarily in verbal memory and executive function, persists between episodes and often limits a patient’s ability to work. 15-30% of people demonstrate severe inter-episode impairment, and people with Bipolar Disorder have a lower average socioeconomic status than the general population, despite having equal levels of education. Although cognitive impairments are more severe in people with Bipolar I, a study found that Bipolar II disorder is linked to lower quality of life overall, even between episodes⁴.

People with Bipolar often have difficulty sticking to their treatment plan. Nearly half of people with BD stop taking their medications regularly at some point during treatment⁶. While there are many factors that contribute to this phenomenon, poor insight, lack of knowledge and denial of illness rank towards the top of the list⁶. Open and honest conversations about the disease, including its severity and time course, is a key component of helping people understand their disorder and stick with treatment. 

Conclusions

Bipolar Disorder is a chronic, severe, and episodic disease. While those with Bipolar II will never experience the full extent of mania, they spend more time in depressed episodes, commonly encounter misdiagnosis, have higher rates of dangerous mixed episodes, as well as increased lethality of suicide, and may even experience a lower quality of life overall. For those diagnosed with this disorder, it is important to understand that it is not simply a less severe form of Bipolar I. It’s a disease with real risks and should not be taken lightly.     

“Comparison is the death of joy.”

Mark Twain

With fears about the Coronavirus epidemic spreading like, well, an epidemic, the public response to the virus has ranged from complete apathy to full on panic. Face masks are flying off the shelves, “I survived Coronavirus” t-shirts and “Coronavirus protection kits,” are being sold on E-Bay, and a virus-themed outbreak game called Plague Inc. is hitting record numbers on its app. There is a plague of misinformation on the Internet, and one of the most frustrating aspects is the constant conflation of the flu and Coronavirus. They are two distinct diseases, with very different epidemiological profiles, but it has become wildly popular to compare the two. Some articles point out that the Flu infects millions of people every year, dwarfing the Coronavirus outbreak. Others argue that Coronavirus is both more deadly and more novel. At its most basic, the comparison is meaningless; a juxtaposition of apples on oranges. But since comparisons are running rampant, let’s make sure we’re getting the facts straight.

Virology

The Coronavirus causing the current outbreak, recently named COVID-19 by the WHO, is not the only Coronavirus in existence. It’s not even the only one that can infect people. Named for the crown-like spikes covering the viral surface, most Coronaviruses reside in animals but there are seven types that can infect people. Most of these Coronaviruses are very common, and usually cause no more than a mild-to-moderate upper respiratory infection, not unlike the common cold. However, some Coronaviruses have been known to cause outbreaks, including the Middle East Respiratory System Coronavirus (MERS) and its better-known cousin Severe Acute Respiratory System Coronavirus, or SARS. COVID-19 is the seventh Coronavirus known to infect humans and was only recently discovered.

There are four types of flu viruses – A, B, C and D – though A and B are the most common causes of human illness. Within these two types, there is a dizzying variety of subtypes, lineages, clades and sub-clades, determined by the viral proteins. There have been several killer flu pandemics over the last century, including the Spanish Influenza of 1918, the Asian Influenza of 1957, the Hong Kong Influenza of 1968 and the Swine Flu of 2009.

Signs and Symptoms

Both Coronavirus and Flu viruses cause an upper respiratory illness characterized by fever, cough, fatigue, muscle pain, shortness of breath, even diarrhea and nausea. Transmitted through respiratory droplets, both viruses spread easily from person to person. Both diseases can progress to pneumonia, kidney failure, and even death.

Treatment and Prevention

The flu vaccine is based on the varying proteins on the viral surface. Every year, scientists utilize epidemiologic studies every year to try to determine which strains to include in the vaccine. A recent study by the CDC showed that the flu vaccine was about 40% effective in preventing severe enough flu symptoms to need to see a doctor. But the vaccine has other benefits, including preventing and reducing the severity of complications. Coronaviruses have no known vaccine. Scientists are currently working on a vaccine for COVID-19, but it won’t be ready for at least a year.

Treatment for both Coronavirus and Influenza is mostly supportive, with respiratory support given if necessary. Antiviral medication such as Tamiflu, has been shown to speed up recovery in patients with the flu. Such results have not been demonstrated in COVID-19, yet some patients continue to receive it.  

Transmission

COVID-19 is incredibly contagious. While studies have really just begun, initial estimates show that each person infected could spread the virus to 1.5-3.5 other people without effective preventive measures. In contrast, people with the seasonal flu tend to infect only 1.3 other people. While this may not seem like a large difference, it can lead to a drastic increase in the total number of people infected. Furthermore, COVID-19 has a longer incubation period, which allows for increased transmission. Most people with the Flu exhibit symptoms within 2-4 days of infection. With Coronavirus, it can take as much as 2 weeks from infection to first symptoms. The patient is contagious and spreading the virus that whole time. However, risk of transmission can be decreased with effective public health measures, such as isolation and hand-washing.

Epidemiology

As of February 13th, 2020 there are over 59,804 confirmed cases of COVID worldwide, with 1367 deaths, according to China’s National Health Commission. Most of those are in Hubei Province, China – the Province containing the outbreak’s epicenter, Wuhan – but the disease has now spread to 25 countries, including the USA. This puts the fatality rate of Coronavirus at 2.2%. However, many believe the NCP’s mortality rate may increase as the disease continues to spread. A recent JAMA study of patients in Wuhan found a mortality rate of 4.3% and rapid person-to-person transmission⁵. Older patients and those with multiple comorbidities were the most likely to be the most seriously affected.

Every year, influenza affects somewhere between 3-11.3% of the US population; a staggering 27 million people. The mortality rate varies widely from year to year. In the 2017-2018 season, a particularly nasty outbreak caused more than 80,000 deaths. In previous decades, the average was 56,000. This means the recent mortality rate was somewhere between 02.-0.3%, less than 1/10^th of the current estimate for Coronavirus.

Two diseases: one preventive strategy.

COVID-19 and Influenza are two viral respiratory diseases that are at once very similar and quite different. Both need to be taken seriously. COVID-19 has a high mortality rate, is easily transmissible through respiratory droplets, and has no known vaccine or specific treatment. So far, it has only killed a relatively small number of people, but scientists are not sure how this outbreak may evolve over time. If you live in the US and do not work in healthcare, your chance of coming into contact with COVID-19 is exceedingly small. Influenza, on the other hand, has a relatively low mortality rate, but is exceedingly prevalent, so it kills tens of thousands of people every year in the US alone. Luckily, there is a vaccine that can both prevent the disease and reduce severity of complications, as well as a targeted treatment that helps to speed up recovery. No matter where you live in the world, you are likely to encounter some strain of influenza this winter. So whether you’re trying to avoid the Flu or worried about a global worsening of COVID-19, your standard precautions remain the same. Wash your hands, cough into your elbow, and don’t go to work if you feel sick. And get your flu shot. After all, an ounce of prevention is worth a pound of cure.