COVID and Rosh Hashana and Yom Kippur by Mendel Singer PDF (Full version with appendix)
We’re all tired of COVID. Tired of hearing about it. Tired of having our lives revolve around it. Tired of wearing masks, not seeing elderly relatives who are isolating. We just want things to be normal again, even more so with Rosh Hoshana/Yom Kippur coming up. Can we just have a normal yomim n’oraim? Doesn’t Klal Yisroel need it now?
We are all suffering from Corona Fatigue. Hashem, take this away! Let us daven and learn in peace, let our children have normal school.
Nonetheless, like it or not, Rosh Hoshana/Yom Kippur raises substantial and unique challenges we don’t face on a typical Shabbos and this needs to be carefully considered by shuls in their ongoing heroic efforts to maximize normalcy and safety for their kehilla, and by individual making their person choices about where to daven. In this public letter I will discuss the special health challenges of Rosh Hoshana/Yom Kippur, and end with a moshul. After that is an appendix that addresses the following questions for those willing to read longer:
- What is the state of COVID in our community and in the county?
- It is so confusing! Things keep changing and there’s so much conflicting information!
- Hospitalization and deaths are down – why? Has the virus mutated into a less lethal form?
- Where do we stand in terms of treatment for COVID?
- Immunity after having COVID
- Fair expectations about a vaccine
- Herd Immunity
Why trust me? I write from my perspective as a professor of public and population health for 25 years (and a Vice Chair for 6 years) at the distinguished medical school of Case Western Reserve University with over 70 publications in peer-reviewed journals, despite my primary focus on education. These publications include research in infectious diseases: HIV, Tuberculosis, Rotavirus, Hepatitis A and C, and antibiotic resistance in respiratory infections. I have worked with the county health department, and been honored by it with a resolution after a mumps outbreak in our community about 10 years ago. I have done one study of my own related to COVID, recently published in the top Rheumatology journal, Annals of the Rheumatic Diseases. Since I have taken hydroxychloroquine in the past for my auto-immune disorder and am supposed to go back on it long-term, it was personally disappointing to determine that this drug provided not the slightest benefit in preventing COVID. As I tell my students, never apologize for results – the truth is the truth. Just be sure you have the right methods. I know good study design and proper statistical analysis. My opinions are totally driven by what the data says and what it doesn’t actually answer.
Let me preface the discussion by stating that as a professional I can supply information to help people and Rabbonim understand the health situation and risks. I am not going to make specific
recommendations for the following reasons:
- There are differences in shuls in terms of: how many elderly or otherwise high-risk congregants, available space, air circulation, windows, or the outdoor space or economic wherewithal to
create optimal solutions such as davening outdoors. Obviously, in terms of other communities, there are differences in numbers of cases. - Solutions have to work for the kehilla. Rabbonim are constantly doing a balancing act. Prioritizing safety is important, and so is shalom – always a key ingredient at a time of judgement of Klal Yisroel. There will always be people who think measures don’t go far enough and others who think those same measures are too extreme.
- The decisions end up involving criteria that are way above my pay grade, e.g. halacha and hoshkofa.
Have rachmonis on your shul Rav! The pandemic has put enormous burden and stress on our Rabbonim. And we certainly can’t just dismiss it by saying “that’s why they get the big bucks”!
Remember to be extremely sympathetic to, and be mispallel for our Rabbonim – an amazing group that distinguishes our community.
Shalom!!! The pandemic creates a situation that is rife for machlokes, and at the time of year when shalom is most important! People are stressed and have conflicting opinions about COVID. Some of us, myself included, have had tense situations over COVID.
What are the special COVID health challenges of Rosh Hoshana/Yom Kippur?
Transmission of the virus is very dependent on the volume of exposure. Think of other viruses and when one child gets it, a sibling that sleeps in the same room is more likely to get it than other family members. And even though every family member will have some exposure, some won’t get it. Exposure is dependent on length of time, distance, air circulation, wearing face coverings to reduce how far droplets go, the force of the droplets (regular speaking voice vs. projecting one’s voice to speak loud or sing, speaking vs. coughing vs. sneezing). Volume of exposure not only matters in terms of getting infected, but it can also affect severity of infection. When a small volume of exposure does cause an infection, it is more likely to result in an asymptomatic or mild infection.
The risks posed by Rosh Hoshana/Yom Kippur are so much greater than a typical Shabbos that it requires greater vigilance for the following reasons:
- The very long hours together means great exposure to those davening nearby. More people walking around at times. Many people using the same bathroom. More time for people to cough or sneeze.
- Lots of singing and louder davening means voices being projected and more droplets being released and with greater force, carrying further.
- Crowding. Whatever limitations shuls put in place for Shabbos may not be sufficient for our holiest days. More women want to come to shul, and that often means more children who are also capable of both getting infected and spreading COVID. While there is some weak evidence that kids under age 10 may be less likely to get infected or transmit, it is still far from clear to what degree that is true since we don’t generally test kids.
- Let’s face it, everyone desperately wants to be in shul on our holiest days! Any Rav can recount the many times people have not taken important medications or fasted on Yom Kippur when their health demanded differently. It’s awfully easy to say “it’s hardly even a cough”. A little sneezing –“probably allergies”. A fever? It’s yom tov and you can’t take your temperature. How easy it is to say it’s probably just a little warm in the house. Maybe the slightest low-grade fever, “that’s nothing”. How can I daven at home on Yom Kippur? I need the zechus of being judged with my kehilla. This may be the greatest threat, that people who are actually mildly symptomatic and very infectious may come to shul, be there for many hours, singing and davening loudly and using the bathroom creating substantial exposure to others. A possible solution that would require a halachic question to your Rav: can a shul pay a goy to do a no touch forehead temperature scan on people before they enter the shul on Shabbos or Yom Tov? Maybe done on the 1st evening and each day of Rosh Hoshana, and the evening and day of Yom Kippur? Again, way above my pay grade.
I will end the main letter with a moshul (followed by an appendix). When COVID first broke out, we all searched for the cure – the treatment that was already out there that would end this pandemic. Early on there were times we got our hopes up. Some treatments worked so well in the lab! But not so well in people (this happens all the time). Then we got our hopes up that a vaccine would come quickly and end the disease. But even with heroic efforts all over the world and over a hundred different vaccines in progress and everything being fast-tracked to the extent possible while maintaining safety, it still takes longer than we hoped. We continue to wait.
Meanwhile, face masks and social distancing have been effective in reducing transmission. And we’ve been chipping away at the disease. While everyone’s attention was on a cure or a vaccine, we’ve been making progress in managing the illness and reducing mortality. Steroids have been shown to cut mortality in patients on ventilators by as much as 20-30%. Some other drugs have shown modest reductions in mortality. We’ve learned when to use ventilators and when less invasive sources of oxygen can be used (including some very creative reworking of existing equipment). The disease is still around, but all these measures together have reduced the number who are hospitalized and the number dying.
In this moshul, COVID is the yetzer hora. We often hope we can find a cure for the yetzer hora, some major transformation through radical change in our avodas Hashem. Sometimes that works. More often, it doesn’t. The vaccine represents Moshiach, the ultimate cure that completely ends the yetzer hora, which we must daven for and work towards making a reality. The face masks and social distancing – this is keeping away from situations where we are more likely to yield to the yetzer hora, as we are taught that it is better to stay away from temptation than to challenge the yetzer hora on his turf. All the treatments and improvements in clinical practice in managing the disease – this represents the little by little approach to teshuva recommended by the baalei mussar and chassidus. Yes, sometimes we can make jumps and sustain them. In between, we try to keep chipping away, improving little by little. When we stop and look back, we be quite surprised to see that we’ve come a long way! The tried and true approach to teshuva.
May our tefilos this Rosh Hoshana and Yom Kippur be successful! May we merit the ultimate spiritual vaccine, Moshiach Tzidkeinu, speedily in our days!
Kesiva v’chasima tova!
Mendel E. Singer, PhD MPH
Esther L Greenberger says
Thank you for your beautiful and informative words! K’siva V’chasima Tova to you and your family! May HKB”H bentch all of Klal Yisroel with gezunt and a Shana Tova U’misuka!
mendel singer says
Thank you so much and the same to you and your family!
mendel
Laura says
Great article! Where can I read the appendix?
mendel singer says
Thank you for the kind words!
The post has a link to a PDF that has the appendix at the end.
K’siva v’chasima tova!
Ephraim Spero says
I am very proud to be a friend of R’Mendel
Ephraim Spero
mendel singer says
How nice to “hear” from you! So many wonderful Shabbos meals I had with your beautiful family before I got married. You were always a paragon of mentschlichkeit. You and your wife are missed here. K’siva v’chasima tova!
RG says
This article does not provide any sources for any of the claims made. There are many health professionals and studies that provide a very different view of the situation we are currently in. There is evidence they can provide for their opinons. I am curious to know how many patients with Covid-19 you have personally treated. Many doctors who have personally treated covid can attest to the fact that hydroxy worked very effectivley for hundreds of their patients.
Mendel Singer says
Thank you for your response. I know there are others who feel the same way. We have been bombarded with information and much of it is biased. You seem to be focusing on hydroychloroquine (HCQ), which is the most politicized. On the left, they have overstated the risks, and on the right they overstate the benefits. Let’s ignore the media and their slants. On the side against HCQ we have the overwhelming majority of experts, including our leading hospitals and the major professional societies who review the evidence and have all come to the same conclusion. They follow the same approach as they do with all medical issues. They review the research literature and differentiate between well done studies and poorly done studies. They know what is real evidence and what is meaningless, and panels of experts create guidelines. This is how things work in medicine. Most doctors look to these leaders in their field for direction. On the side for HCQ you have one expert, Dr. Harvey Risch, who now relies inexplicably on the kinds of studies he normally considers to be unreliable and normally would never be allowed in a research journal and doesn’t even mention the best studies that work against him. Counting patients from a 2-page Google document from a non-researcher whose numbers keep changing? Really? And here’s a published response taking him to task for his gross misunderstanding of one of the better of the terrible studies he relies on. See https://academic.oup.com/aje/advance-article/doi/10.1093/aje/kwaa155/5873637.
Dr. Risch’s colleagues, also distinguished, clearly disagree with him vehemently – see their public response here, which has useful links, including evidence-based reviews by the Infectious Disease Society of America, against HCQ: https://medium.com/@gregggonsalves/statement-from-yale-faculty-on-hydroxychloroquine-and-its-use-in-covid-19-47d0dee7b2b0. Why believe the one person against the huge numbers against him? Truth shouldn’t be determined by whether they say what I want to be true.
Yes, there are doctors who claim incredible results with HCQ. There are anecdotal reports and very poorly done studies for many totally disproven therapies – that’s why we don’t use them.
As for outpatients with mild symptoms treated early, as I said, the jury is out. The one large randomized trial by Skipper and colleagues had over 200 patients getting hydrxoychloroquine (some with azithromycin and zinc) and they had 1 death, just as in the control group. But this group of patients does extremely well regardless of treatment. Trying to find a benefit to HCQ would require an enormous number of patients. As I said, the jury is out. For hospitalized patients, or for prevention – the jury is in and it doesn’t work.
Yes, there are doctors who say HCQ works. We have several hundred thousand doctors in this country. You can always find some who have an opinion that is contrary. But anecdotal evidence from doctors isn’t considered real evidence for good reasons, and the history of medicine is filled with incredible anecdotal reports of treatments under non-pandemic conditions that had spectacular results and were later determined to have absolutely no benefit. Anecdotal reports typically have no comparison group, they don’t follow up on patients with bad results who switch doctors, they don’t count patients with bad results for reasons they decide on the spot and don’t exclude patients with good results that met the same criteria, they may have many patients who aren’t properly diagnosed, etc…. The list goes on and on. Again, those who find HCQ doesn’t work are never heard from, so you only find out about the ones where they think HCQ works. That’s another bias.
There’s another reason not to believe the doctors who claim it has worked for them. If the vast majority are going to get better anyway, how do they know anything is due to HCQ? Doctors have found patients with COVID-19 can go from doing very well to doing terribly, or the reverse, very quickly. You need well designed studies on large numbers of patients to know what works. People have great results taking antibiotics for upper respiratory infections with antibiotics – but the vast majority are viral and the drugs don’t do anything, they just get better anyway. Same for HCQ and COVID – if the patient gets better with treatment, there’s no way for the doctor to know if it is because the drug worked or because they would have gotten better anyway. That’s why we need good studies – the kind medicine is based on.
Saying there are studies for and against HCQ creates a false equivalence. The quality of the evidence against HCQ is greatly superior to that in favor of HCQ.
Let’s get our medical advice from proven, respected sources and not the media or internet at large. This has worked well for us in the past. Why stop now?
mendel
EA says
I believe its hydroxy used together with zinc that will cure covid. Both need to be used together. Evidence does show this and it is proven.
mendel singer says
Using usual standards of evidence in medicine, there is no evidence, let alone proof, that hydroxychloroquine and zinc is a cure, or even provides benefit. Using your threshold for “evidence” would mean we have many cures for cancer. I know of 2 sources of this so-called evidence, Dr. Zelenko and the NYU study of hospitalized patients. The NYU study was at least research, though their May 8 report posted online has yet to go through the peer-review process and remains unpublished. They conclude their report with “In light of these limitations, this study should not be used to guide clinical practice. Rather, our observations support the initiation of future randomized clinical trials investigating zinc sulfate against COVID-19.”.
As for Dr. Zelenko, consider the following:
1. He initially claimed to have seen 699 patients in the prior 7 days with 100% success, meaning no deaths. He didn’t test people for COVID. The vast majority didn’t have it.
2. He later claimed a total of 405 people and posted results with almost no info about the “study” and then another 450. Yet, when he finally got 2 German researchers to work with him to turn his work into a real study, he ended up with just 141 patients, 4 hospitalizations and 1 death. How did he choose these 141? He knew all of their results before he made the rules to be included in the study! Maybe the hodgepodge of This wouldn’t be so bad if he then used reasonably standard criteria, but he didn’t. The paper acknowledges the very odd set of rules for inclusion into the study. How do we the criteria filtered out people with bad results? He also included 27 patients based not on initial testing, but on antibodies – presumably from his earlier untested patients. But he doesn’t explain why these 27? What about the large number of other patients he treated without testing? Anyone he treated earlier and died – they aren’t included. Anyone he treated earlier and did poorly may have changed docs after being told he was being given a cure. This report still lacks much of the basic information needed to evaluate the study that is always included in a real study.
3. He then compared his results based on carefully set criteria to public data that had no information about the patient, such as severity of symptoms. This group likely contains a lot of severe patients. But he provides no information even about the time period the data is from, e.g. are Dr. Z’s patients taken after the initial explosion in cases and the public data mostly from the initial time when hospitals were overcrowded?
4. Dr. Zelenko has readily admitted he knows nothing about research, which became quite apparent when he described his study as being FDA approved when in fact it had only been given ethical approval at a local hospital.
5. There are many more flaws in this “study”. There are good reasons medical experts consider these reports anecdotal and not real evidence.
Nonetheless, the lack of evidence “for” HCQ+Zinc (with or without azithromycin) is not a proof “against”. I doubt it’s anything remotely like a cure, but it could have some benefit. We just don’t know yet.
mendel
Yitzchok Reis says
If I may, I would like to add that:
1. I have personally know Dr. Singer for 23 years, and know him to be both a yirei shomaim, and expert in the field of Epidemiology at Case Western.
2. Unfortunately, a lot of misleading and anecdotal information has been disseminated that is not based on science. Developing a vaccine is not something that can be rushed to them market, as there area three clinical trials, and follow ups, before it reaches the market, not to miss the required approval from the FDA. Dr. Salk would not allow his polio vaccine to be available to the public until after 3 years, so as to be sure that it was safe.
The Trump claim that a malaria drug worked is not science, since it never was tested for efficacy of immunization from COVID-19; one has nothing to do with the other.
The use of zinc and vitamin D is of no use to anyone, and is scoffed at by the medical community. The short and sweet of over the counter supplements is that Americans have the richest urine in the world. But kol hakovod if it makes you THINK it works, since in some cases there can be a placebo effect. But nobody should for a second believe that taking a pill that you can buy at Walgreens or CVS will be of any use at all against COVID.
3. The lack of care that I see of not wearing a mask at ALL times is not just a pet peeve of mine, but it is a danger to everyone in Cleveland. The frum community has to come to a consensus that we are going to heed the guidelines of the CDC and our doctors. There are people that scoff at vaccines, believing that they either don’t work or that they even trigger disease. That’s how we ended up with an outbreak of measles in the New York and Californian area. There are even people drinking “raw” milk! Guess Lous Pastuer had no idea what he was talking out, ay? Welcome back to the 1800s, when death from communicable diseases was claiming many of our ancestors in their 40’s or even infancy. Aint TB great?
4. Denial will not make it go away!
5. Lastly, how many people need to be in hospitals clinging to life, or G-D forbid pass away, before people come to their senses? Come to think of it, it’s like smokers, who are killing themselves from the first addictive puff.
Thank you for hearing me out. I pray to G-D that we come to our senses. COVID is not going away, and people ARE and WILL get it without using their G-D given common sense.