Ceremony Re-Reimagined: The Thayer Street hot spot gets even more creative

The “People’s Choice” winner of RI Food Fights Iced Coffee challenge came from an unexpected spot this year: Ceremony, a café on Thayer street best known for its tea ceremonies. When Ceremony first opened its doors, just before COVID struck Rhode Island, owner Michelle Cheng talked to Motif Magazine about her vision for her business as “a tea house: reimagined,” where people could sit down for high quality, single-estate tea tastings, similar to whiskey or wine tastings.

But when restaurants and cafes had to transition to take-out menus, Cheng was forced to reimagine her business yet again. And the solution she arrived at is genius.

“Since our tea ceremony services were limited, I knew we needed to expand our to-go and creative menu items. The way it works is: you choose a base — ranging from Japanese green teas to espresso — and your style — from a latte to a spritz — and it’s like building your own poké bowl, but with drinks.” 

There are currently four base options to choose from: a matcha tea, a green tea, a black tea and an espresso. There are also four styles of drink: latte, cappuccino, Americano and spritz. There’s no upcharge for milk preference (regular, soy or oat milk), and you have a choice of add-ins: house-made strawberry or lavender syrup, adzuki redbean, CBD shots, brown sugar bobas and seasonal syrups.

“I realized that people understand how to order coffee, but they don’t understand tea options,” Cheng said, “so we have a signature menu with some of our favorite combinations. It’s brought in a new wave of customers and a different clientele, which has been great for us.” 

For journalistic integrity, I thought it would be wise to try at least three of these build-your-own drinks, so I ordered:

-(iced) Spiced Chai with a shot of espresso (ie, a dirty spiced chai)

-(iced) Lavender Matcha with brown sugar bobas

-(hot) Hojicha — the Japanese green tea — Latte with maple syrup

These are — and I’m not just saying this — the best tea drinks I’ve ever had. As someone who completed a Bubble Tea crawl two years ago, I’ve had my fair share of bobas, but this Lavender Matcha topped the charts. 

“I never knew there were different grades of bobas you could buy,” Cheng said, “so I learned a lot this summer. Even within Grade A (which we use), we had to decide on a specific level of chewiness!” she laughed. “We make our own brown sugar and cinnamon syrup to soak them in. A lot of places use a honey syrup, but we wanted to be mindful of our vegan customers. Vegan bobas teas are hard to come by.” 

Whether you are feeling adventurous enough to build your own drink on your first visit, or want to order from their signature menu, I promise you will find something that excites you. “The black sesame latte with a scoop of strawberry sauce is a current late-night favorite — like dessert in a cup,” Cheng said. I am already planning my next visit.

“No matter how hard things get, I have fun with it,” Cheng said, which, coming from someone who opened her business two months prior to a global pandemic and had a baby mid-quarantine, redefines hard. “The prospect of coming up with new recipes always excites me. My motto is ‘Be unique; be creative.’ The most dangerous thing is to become comfortable.”

231 Thayer St, PVD

Instagram: @ceremonypvd

Order online: ceremonypvd.com

The Scoop on French Onion Soup: We rounded up the best options on offer in PVD

The colder months are ahead, and nothing warms bodies like a steamy serving of French onion soup. So our French onion enthusiasts rounded up a variety of some of the yummiest choices around. We restricted our research to Providence restaurants that serve this tasty concoction year-round, though you can find it off-and-on in many other locales as the season progresses.

Red Stripe

Red Stripe’s version of this delectable dish comes bubbling in a crock with a mouth-watering presentation and steamy aroma. Gruyere cheese blankets a fresh baguette slice, and the rich, dark broth is packed with Vidalia onions, making it not only the sweetest, but also the chunkiest soup in town. 

The Congress Tavern

“Everyone here orders the French onion soup,” brags John, a waiter at The Congress Tavern. Their secret? Brandy. The brandy in the broth blends with white onions and gruyere cheese to create The Congress Tavern’s signature flavor. The soup is served in a crock with a slice of bread on top.

The District

The French onion soup at The District has a perfect combination of sweet and tangy flavors. It’s also one of the most affordable options on our list. One of the key ingredients in The District’s version of French onion soup is the homemade croutons buried beneath a layer of cheddar cheese. These little morsels of bread are baked in a wood-fired oven and sprinkled with parsley and garlic for an amazing addition to the dish.  


Who would have thought an Irish bar could do French so well? Murphy’s, like The District, gives a lot of bang for your buck and offers two size options: cup or bowl. This soup features a helping of Swiss cheese on top, which makes this a perfect choice for those who prefer salty over sweet flavors in their French onion soup. The crouton that floats on top adds a a little bit of crunch. 

Pot au Feu

For those preferring to take their soup on the run, Pot au Feu, Providence’s premiere French restaurant, is the way to go. Bob Burke, the restaurant’s owner, reveals that the secret to their French onion soup is using chicken stock rather than beef. “The chicken stock allows the sweetness of the onion to come forward,” he says. Burke hits the “sweet spot” of flavors by allowing the Spanish onion to act as the sweet and the cheese to act as the salt. Though currently offering takeout only, Burke expects to open indoor dining again soon, with many COVID-friendly enhancements, like a special germ-reducing HVAC system. For now, patrons can enjoy this dish on the nearby pedestrian bridge.

Tardy Tests: K-12 testing delay keeps teacher out of work

Natalie Andrus Fleming is a school psychologist based at the Asa Messer Elementary school in Providence. On Wednesday, September 16, the third day after schools partially reopened in Providence, one of two cities in RI that were not approved for full in-person reopening due to high COVID-19 rates, Fleming said she was directed to stop coming to work and to self-quarantine. “I have allergies and routinely get a sinus infection at the start of every year… I was sneezing, had congestion and a headache so my school nurse told me I had to get tested as those are also symptoms of COVID. She was under the impression that it was a rapid test and I would be back the next day,” Fleming told Motif.

RI is the only state that set up a completely separate parallel testing system for K-12 students, teachers and staff. In a statement on September 15, RI Gov. Gina Raimondo said, “To stay ahead of the virus and keep students, teachers and other school employees safe, we’ve geared up to provide an additional 5,000 tests every day specifically for our school community. If you work at a school and you need a test, or if your child needs a test, you can schedule a same-day test by calling our dedicated Pre-K-12 COVID Test Scheduling Service at 844-857-1814. The service is available seven days a week, from 7:30am to 9:30pm. This scheduling line is reserved for students, teachers and staff who have symptoms, or who have been in close contact [with] someone who is positive.”

Fleming called the hotline and scheduled a same day test, and she went for sample collection (by swab) at 1pm on September 16, the same day the school nurse told her to get tested, at the Pastore Center site in Cranston. She said she had some difficulty locating the testing facility due to lack of signage, but eventually sample collection took place without a problem. Per protocol for someone who displays symptoms, Fleming’s samples were submitted for both a rapid antigen test and a laboratory PCR test. She received the rapid antigen test results by 7:30pm, but because that type of test is less accurate than the laboratory PCR test and is more prone to false negatives, she was still not permitted to return to work until her laboratory PCR test results were in, which the state is committed to turning around in at most 48 hours.

By Sunday, September 20, Fleming was still looking for her laboratory test results and had been out of work for three days. On Monday morning she told Motif, “I called the hotline yesterday (Sunday) as I still had no results and cannot go back to school…” The woman who answered the hotline, according to Fleming, “indicated that labs are backed up and it could take another 24-48 hours but also could not confirm a definite timeline for when I would receive them and be able to get back to school.” Fleming said, “The woman I spoke to said she checked the portal” and saw the laboratory PCR test result had not yet been entered, apparently referring to the database maintained by Dominion Diagnostics, the laboratory based in North Kingstown tapped by the state to provide local testing services.

With Fleming’s permission, Motif contacted the RI Department of Health (DoH) about the delay. Joseph Wendelken, spokesman for DoH, said there is no backlog of testing and that “PCR test results are becoming available in roughly 48 hours.” With regard to Fleming specifically, Wendelken said her test was completed Friday, September 18, and should have been available to her in their portal at that time. He speculated that there might have been miscommunication.

Screenshot of e-mail to Natalie Fleming from RI Department of Health, sent 2:00pm Mon, Sep 21.

Five days after sample collection but only hours after the exchange between Motif and Wendelken, Fleming reported receiving an e-mail message time-stamped as sent at 2pm on Monday, September 21, directing her to establish an account with the portal to obtain her results. Motif followed-up with Wendelken: “That seems inconsistent with her results being completed Friday. Are you sure?” As of Wednesday, September 23, DoH has not replied.

Fleming confirmed her laboratory test was also negative, but by that time she had missed four days of school waiting for test results.

Surviving and Thriving: Vegan, vegetarian eateries face the pandemic in PVD and Pawtucket

Prior to the pandemic, you could often find Rob and Uschi Yaffe seated at the end of a long, reclaimed wood table in the middle of their casual fine dining restaurant, the Grange. The brunch rush bustling around them; mason jars filled with sweet tea and tart lemon wedges or strawberry and peanut butter smoothies are delivered on trays to each table of the dining room. Servers slip through the archway to the kitchen, carrying out hot plates filled with spicy home fries and vibrant green avocado toast. The Grange presents each diner with a down home, farm-to-table vegetarian meal in a comfortable, nostalgic environment. 

The Grange is just one of three storefronts owned by Rob and Uschi. Along with vegetarian food spot Garden Grille and vegan bakery Wildflour, they support the ever-growing group of people with vegan and vegetarian lifestyles in Providence and Pawtucket. At the heart of the Yaffes’ businesses is their desire to foster the beliefs and values of the people of Rhode Island. “It’s always about the community. It’s always around the core value of what does the community want? What do they need? What’s not being done?” Rob said. All three of their restaurant spaces are full of soul and spirit, each one welcoming and nostalgic. Rob and Uschi hope to continue to foster this growing community, but the COVID-19 pandemic has created a whole new world of challenges in carrying on this vision. 

When whispers of a virus afflicting China reached the East Coast, it was easy to feel the problem was far away. That was until early March, when managers first starting hearing about employees feeling unsafe coming to work. Prior to the official shutdown of dine-in restaurants and bars, Rob held a meeting to discuss next steps; it was obvious the virus was spreading. “It was a Monday, we were having a meeting of what are we doing? What’s the best thing for safety of staff and customers?” Rob said. “And we were like shut them all down.” That same day, March 16, 2020, Governor Raimondo officially announced the closing of bars and restaurants. 

The food service industry as a whole has been hit hard by the pandemic, but the Yaffes’ businesses are finding their way through the challenges. They’ve supported their employees, helping feed them and their families as well as covering health insurance through the first month of the pandemic. They also received assistance from grant money, and fortunately are still making a profit amidst reopening. “Both Wildflour and Garden Grille are still strong enough to make a little bit of profit during COVID,” Rob said. “Right there that’s something I’m unbelievably grateful for. If you can make money during a pandemic, that’s quite a business that we’ve all created.” But Rob says every day is still a challenge. 

In addition to financial struggles, the pandemic has taken an emotional toll on restaurant owners. “There is no coming together as community anymore, we don’t have gathering places anymore,” Rob said. “For me it was all about bringing people together, connection, creativity, just that buzz of human activity and community building.” 

Prior to the pandemic, it was incredibly common to see Rob and Uschi bouncing about their eateries, greeting customers with hugs and handshakes, warm smiles and easy conversation. For a while Rob tried to maintain this relational aspect, standing outside the restaurants during business hours each day to greet customers coming and going. “My connection to the businesses were always relational. When you go for a pickup it becomes transactional. So I had this need to add some kind of relational aspect to it, and I did that for six or seven weeks … but not having that initial facial recognition and contact, no shaking hands or giving a hug, you lose that sense of bonding that makes the conversation flow,” Rob said.  

By the end of April, early May, Rob hit his breaking point. “All my passion, all my vision, all my everything, just vaporized,” Rob said. While the Yaffes’ still own their businesses, they have largely stepped away from operations, leaving the restaurants to their reliable managers Jon Dille and Deanna Lockhard. “I’m very grateful for the staff and Jon and Deanna for what they are doing,” Rob said. “We had a core group of people that really came in with the intention of let’s come together and make this work, and I’m very grateful for the people who came in with that frame of mind.”

The businesses continue to find ways to reach their customers and foster community, though challenges still arise. “Customers coming in for the most part are fine, they’re good, but everyday you’re dealing with people who don’t accept the rules and the new way of procedures on how to keep things safe. Then you’ve also got staff that don’t feel safe working.” The restaurants require customers wear masks and encourage frequent handwashing. For employees, masks, frequent handwashing and health checks are in place. 

The Grange, Garden Grille and Wildflour are serving the community as best they can given the times. Currently, all three restaurants are open for takeout, and the Grange and Garden Grille offer outdoor dining options. As far as indoor dining and delivery, the restaurants don’t currently see these options becoming available anytime soon. “We’re not going to open up, at least not now. I don’t think it’s cool, I don’t think it’s safe,” Rob said. “I think this period that we’re in, it’s going to pass in a year or two. The whole emergency crisis part of it will be over.” Until then, the restaurants will continue with social distancing measures, so remember to wash your hands and wear your mask on your next trip to the Grange, Garden Grille, or Wildflour. 

Math Behind Group Size Limits in the Pandemic

In RI, during the COVID-19 emergency Gov. Gina Raimondo has limited informal social gatherings to no more than 15 people and in-person school classrooms to stable groups of no more than 30 students. Where do these numbers come from? The governor has described them as “judgment calls,” but she is not just arbitrarily picking numbers.

At a press conference on Sep 4 (about 45m30s in) I raised this topic with Dr. Nicole Alexander-Scott, director of the RI Department of Health, and she explained that the limits have to be kept small so that, if there is an outbreak, contact tracing and case investigation staff are able to carry out their responsibilities quickly enough to prevent secondary and even tertiary transmission of the virus to others.

But the main issue is that risk of encountering an infected person increases rapidly as group size grows larger, and this is a basic mathematical fact. How does that work?

For the sake of explanation, let’s assume each person coming to your party has a probability of arriving infected of 20%, which is another way of writing 0.2. It should be obvious that, if your party has only a single guest, then the chance of any of the guests being infected is therefore 0.2. What if there are two guests?

It turns out to be easier to compute the probability that none of the guests arrive infected: with a single guest, their probability of being not infected is 1.0-0.2=0.8 (or 80%). With two guests, the probability that both are not infected is 0.8×0.8=0.64 (or 64%). With three guests, the probability all are not infected is 0.8×0.8×0.8=0.512 (or 51.2%). And so on.

This property of multiplying a number by itself repeatedly is called “exponentiation,” often commonly called “raising to a power.” In this case, 0.8 to the 3rd power is 0.512, which we can write using a “caret” symbol as “0.8^3=0.512”.

In general, where the probability of each guest being infected is represented by the letter “p” (which implies their probability of being not infected is 1-p) and the number of guests is represented by the letter “n”, then the probability of all of the guests being not infected, which we can represent by the letter “C” (for “clear”), is (1-p)^n. That’s the sort of thing that’s easy to type into a calculator.

Conversely, if we want to know for a given p (which we can measure experimentally by medically testing people) how many guests n we can allow for a particular risk, we can calculate the n-th root (the opposite of exponentiation) of C. That’s not really sensible when p is as large as 0.2 in our example, but in reality COVID-19 in RI right now is around p=0.02 (2%), implying each guest is 1.00-0.02=0.98 (98%) likely to be not infected.

Probability of no guest infected for individual probability of infection p and number of guests n
(Source: Michael Bilow)

I’ve worked up a handy spreadsheet that figures out the probability that none of the guests are infected, taking into account various values of p and n, and drawn a chart to visualize this. But we can look at some useful reference points.

At p=0.02 (2%), n=10 means our party is 82% likely to have everyone not infected, n=15 reduces that to 74%, n=20 reduces that to 67%, and n=30 reduces that to 55%. This is why the governor is saying that 15 is better than 30: the chance of at least one guest arriving infected rapidly grows to an unacceptable risk, from 1-in-4 to 1-in-2.

At p=0.10 (10%), the numbers fall off a cliff: n=10 means there is only a 35% probability that everyone will arrive not infected, n=15 reduces that to 21%, n=20 reduces that to 12%, and n=30 reduces that to 6%.

Of course, these calculations are a kind of worst-case analysis based upon unchecked community spread. Basic public health measures, especially staying home if you are sick but also observing physical distancing and wearing face coverings, enormously reduce the chance of infecting others. In a structured environment such as a school or workplace, it is possible to enforce this by, for example, screening students and workers as they enter by using simple questionnaires, temperature checks and other methods. If such measures are even 50% effective, that would reduce p from the 0.02 seen in the community to 0.01 inside the school or workplace.

At p=0.01 (1%), n=10 means a 90% chance everyone will arrive not infected, and even n=30 only reduces that to 74%.

The purpose of this analysis is to provide insight into where the governor is getting these numbers and why they differ between different kinds of activities such as informal parties as distinct from school classrooms. Much depends upon how prevalent the virus is in the community, and defining the community is itself a judgment call as prevalence is known to vary between municipalities and even ZIP codes within municipalities. But community prevalence, no matter how chosen and defined, is the baseline from which this kind of mathematical analysis must proceed.

Chazan! Unfiltered: Art and medicine collide in this locally produced biographical graphic novel

Dr. Joseph Chazan, like the character Billy Pilgrim in the novel Slaughterhouse-Five, is unstuck in time. The phenomenon is localized in a new graphic novel Chazan! Unfiltered, which takes a here-there-and-back-again approach to his personal and professional life story.

Rhode Island’s own Dr. Chazan is a nephrologist (in layman’s terms, a kidney doctor), and while the “unfiltered” in the title suggests frank disclosures in its pages, it’s more of a kidney pun. The doctor’s life — at least in comic strip form — is less about shocking revelations and more about his lifetime effort to help people and, in the process, lead a rich and well-rounded life.

We begin with the metafictional framing device of Chazan’s grandson approaching him to say, “Let’s make a graphic novel about your life story.” That, arguably, is a little tired, but once Chazan’s story gets underway, it’s presented with charm, humor and interesting narrative and artistic touches. 

The doctor’s last name is likened to Captain Marvel’s transforming exultation “Shazam!” and no doubt to his Rhode Island patients, Dr. Chazan is a bit of a superhero, since years ago, he led an initiative to introduce something called a “dialysis machine” to our state. Previously, patients had to pack a lunch and go to Boston anytime they wanted the convenience of having their lives saved.

To the graphic novel’s credit, it doesn’t filter out some unpleasant parts of Dr. Chazan’s life, most notably the death of his wife. The graphic novel makes clear that even these darker moments are all part of the bigger picture: happiness, sadness, health, sickness, life and death — they all flow together and around each other in time. 

Given the language level of this book and the way these topics are treated, it’s easy to imagine this book being read by a young adult, teenager or even tween. One imagines a young reader would be most interested to learn that the adult world is not all about work, or all about One Thing.

Dr. Chazan, we find out, enjoys the visual arts. He buys and collects the work of local artists, decorates his offices with their paintings and drawings, and finds no contradiction between being a man of science and a man of the arts.

Several pages of reproduced artwork certainly give the reader an idea of the breadth of Chazan’s artistic interests, but some readers may wish we had at least a single page in which the character Chazan opens up about what one piece in particular means to him. After several pages of reproductions, we literally get the picture: The man likes art.

The comic art itself is from the hand of Erminio Pinque, best known to Rhode Islanders as the founder and director of Big Nazo Lab, makers of large-as-life puppets, masks and sculpture.

While Big Nazo’s creatures can be (entertainingly) grotesque, Pinque’s drawings here have a softer feel and look, which is suitable to his all-too-human subject. Pinque’s rendering of Dr. Chazan makes him look like a human plush doll, which I’m sure the good doctor doesn’t mind.

“Life cycles through us, no matter what we do,” says the comic book version of Dr. Chazan, an analogy to how the blood of life is constantly flowing through our kidneys.  

As readers try to filter the bad from the good to find books worth buying, reading and keeping, make note of Chazan! Unfiltered: It’s a welcome document establishing that superheroes do walk among us, even in Rhode Island.

Chazan! Unfiltered (Never Enough Books, 2020), by Lenny Schwartz (story) and Erminio Pinque (art), will be available in October.

Full disclosure: The editor of Chazan! Unfiltered is Emily Olson, this magazine’s editor, and the artist, Erminio Pinque, is a regular contributor.

Goodbye to You

Knotty’s Cookies

As summer slips into fall, we asked our food writers to reminisce on their best food memories and favorite flavors from the season. This is what they told us:

The most blissful moment for me might have been returning to what felt like normalcy: dining at an outdoor table in downtown PVD at Malted Barley with my flight of amazing ciders and eating their meatball sandwich on an asiago-parmesan pretzel. 

If we’re talking about new discoveries this summer, I’d have to say my top surprises were the Mediterranean Nachos (chickpeas with summer vegetables, hummus and labneh, and housemade pita chips) from The River Social; Piña Colada ice cream from Courtland Club; and Strawberry Milk from KowKow‘s food truck. — Jenny Currier

I’ve noticed that since re-opening, Rhode Island restaurants have really stepped up their game, as the food has been fresh and delicious, the drinks strong and creative, and the service stellar. One dish stands out, however: the lobster roll at Huck’s Filling Station in East Greenwich. I have tried many lobster rolls in my day and prefer the warm buttered variety to the salad oozing in mayonnaise, so naturally I was a bit skeptical when I saw on the menu that this was the latter type. It was nothing of the sort, as mayonnaise was minimal, allowing the flavor of the lobster and herbs to shine. It came served on a brioche roll with a fried green tomato and a tangy remoulade on the side. Paired with perfectly cooked fries and a spicy mezcal cocktail — can’t wait to go back. Next time I’ll add bacon. — Kim Kinzie

For me, it would absolutely have to be the Good Old Buoy Cookie from Knotty’s Cookies in Newport. This gooey yet crisp delight is packed to the gills with flavorful chocolate chips, and the sprinkle of local sea salt on top takes it from #basic to beyond amazing. The menu rotates from week to week, but the stalwart classic is always available. Even though owner Shelby Carroll is only popping up on Fridays and Saturdays from 6 – 10pm in Newport, she has big dreams for future expansion — who knows? These could be the start of a Cookie Revolution! — Morgan Capodilupo

Fall in the Stars: Mother Nature begins to doze, but society does not

Autumn officially begins on September 22, 2020 at 9:30am EDT. Mars, having turned retrograde at the beginning of the month, sits at a harsh angle to the big three in Capricorn: Jupiter, Saturn and Pluto. Mars, having rolled over these three while in direct motion during August, is prepared to roll back over, taking jabs at each one in turn. August brought us COVID spikes, explosions, social and political unrest and here in the Northeast the hottest summer on record and very dry conditions. The horoscope for the Equinox, the picture for that moment in time, promises more of the same.  

Mars kicks off the action on September 28 when the harsh angle to Saturn becomes exact. Simultaneously, Saturn changes direction. When a planet stops and changes direction, the energy of that planet is concentrated. Mars fires up that energy. Mars and Saturn together in any aspect is not pretty. They are justifiably known as the Greater and Lesser Malefic. Things could get ugly. This period, leading up to the Full Moon on October 1, is a prelude of things to come. Mars brings out explosive energy, aggression and mayhem. Amidst all the confusion, deception is in the air. Wait until the smoke clears to try and get the clear picture. At the Last Quarter Moon on October 9, Mars again takes action, squaring off with Pluto. Pluto is the slowest of the slow-moving planets. Pluto entered Capricorn in 2008 (just in time for the financial meltdown) and won’t leave until 2024. The last time Pluto was in Capricorn was during the American Revolution. The USA will have its first Pluto return in 2022. Political and sociological upheavals are a hallmark of Pluto. Clustered now with Saturn and Jupiter all year, birth, rebirth and transformation become the order of the day.  

Before the New Moon on October 16, Mercury goes retrograde. The New Moon in Libra speaks to those Libran things like harmony, balance and collaboration, but that rascal Mars moves in again to stir things up, squaring off with Jupiter. The Full Moon of October 31 may offer a clue to the election. At that time, the Moon in Taurus opposes Sun in Scorpio. Here the Moon is minutes away from a conjunction with Uranus. Moon rules the people, and Uranus rules the unexpected. Uranus is revolutionary. Uranus is unpredictable. Expect to be startled. 

Election Day is November 3, and on that day Mercury goes direct. The last time Mercury went from retrograde to direct on an election day was in 2000, the hanging chad election. Then Mercury went direct after the polls closed. This time Mercury goes direct at 12:49pm EST, well before the polls close. We don’t need a crystal ball to know that voter turnout at this election will be huge, the Moon (the people) in Mercury (the vote) ruled Gemini guarantees a busy and active day. 

Just before the New Moon of November 13, Mars turns direct. While Mars sits on the sidelines for the next month or so, don’t rule him out. This New Moon is a Scorpio New Moon. Scorpio energy is complex and seeks the truth beneath the surface. The Senate, whether lame duck or not, will be active.  There will be lots of discussion, with budgets, debt and foreign policy on the table.  

November 30 brings a Full Moon Lunar Eclipse in Gemini. Venus opposes Uranus in an angular (potent) position. Uranus the revolutionary and Venus the diplomat cross swords. Venus in Scorpio takes no crap, but she is not very diplomatic about it.  

The New Moon on December 14 is a Solar Eclipse in Sagittarius. Here in Providence, Mercury is at the top of the chart. Mercury rules news, cars, trucks, school kids and the daily commute. Mars gives Mercury a boost at this time, bringing energy to all things Mercurial. For us regular folks, this could mean a busy day, lots of conversation, a traffic jam or two, and some news that involves money.

Autumn comes to a close with a major shift in the energy as both Jupiter and Saturn move into Aquarius. They will join together at the Winter Solstice, completing a 20-year cycle and starting anew.  

While society reshuffles and realigns itself, the average person may feel like a cork floating on a rising and turbulent tide, out of control and subject to the whims of that tide. While we are all subject to societal caprice, there are things we can control. Focus on what you can do. Don’t beat your head against a stone wall trying to change something that is beyond your control. While Mars is stirring things up during this period, we can harness that energy and use it positively. Mars with Saturn can be a powerful aid bringing a controlled use of energy — a big project, a fitness plan, a rebuilding of the structures around you, whether physical, emotional or mental. This aspect is not conducive to money falling from the sky, but it is conducive to bringing reward after some concentrated effort. If you’re ready to work up a sweat, you can expect a positive outcome. Stay safe and be well. Wear your mask and wash your hands. 

Get a Flu Shot to Prevent a “Twindemic”: Health experts say vaccinations are more important than ever

“Twindemic” is the trendy buzzword for the nightmare scenario in the medical community right now: seasonal influenza rampaging at the same time as the COVID-19 pandemic, two respiratory illnesses with similar symptoms – fever, headache, cough, sore throat, muscle aches, fatigue – stressing health care resources, especially hospital beds.

“Getting vaccinated against the flu is important every year, but it is particularly important this year because of how important it is that the healthcare system not be overwhelmed,’’ RI Department of Health (RIDoH) spokesman Joseph Wendelken told Motif. “Two of the three field hospitals [set up months ago in RI as reserve to handle demand surge from COVID-19] are ready, should they be needed. We don’t have perfect projections for what the burdens on the hospital system could look like, because flu seasons vary considerably from year to year. We also don’t know how COVID and the flu will impact each other. For example, outbreaks of both virus in the same community would be very concerning. On the other hand, it is possible that some of our infection prevention measures, such as social distancing and mask wearing, will reduce our rate of flu and flu hospitalizations.”

Jason McDonald of the US Centers for Disease Control and Prevention (CDC) told Motif, “Efforts to reduce the spread of COVID-19, such as stay-at-home and shelter-in-place orders, have led to decreased use of routine preventive medical services, including immunization services. Ensuring that people continue or start getting routine vaccinations during the COVID-19 pandemic is essential for protecting people and communities from vaccine-preventable diseases and outbreaks, including flu. Routine vaccination prevents illnesses that lead to unnecessary medical visits and hospitalizations, which further strain the healthcare system.”

McDonald of the CDC emphasized to Motif that the benefits of vaccination accrue to both the public health system and individuals. “For the upcoming flu season, flu vaccination will be very important to reduce flu because it can help reduce the overall impact of respiratory illnesses on the population and thus lessen the resulting burden on the healthcare system during the COVID-19 pandemic. A flu vaccine may also provide several individual health benefits, including keeping people from getting sick with flu, reducing the severity of illness if one does get flu and reducing the risk of a flu-associated hospitalization.”

A spokesperson for the World Health Organization (WHO), who could not be quoted by name in keeping with WHO policy, told Motif, “There are significant concerns with a severe influenza season occurring during COVID-19 pandemic. It will burden already stretched health systems, complicate clinical management and other responses [such as] laboratory testing and contract tracing, as both have similar clinical symptoms, and only laboratory tests can differentiate them.” Asked by Motif what medical interactions there might be between flu and COVID-19, the WHO responded, “No evidence so far to show that infection of one could increase the susceptibility for another. Actually non-specific immune response to one may provide some protection against another for a short time, though unclear how long it could be.”

Screen capture from VaccineFinder.org showing 115 places to get the influenza vaccine for adults 18 years or older within 10 miles of ZIP code 02909 in Providence.
(Source: Michael Bilow)

Vaccines are available from doctors, community health care centers, and pharmacies such as CVS and Walgreens, usually at low or no cost typically covered by insurance with no co-pay. The full cost to a completely uninsured patient at a commercial pharmacy would be about $40 for the normal adult flu vaccine and about $70 for the stronger vaccine with adjuvant for age 65 or older, but such patients could also go to community health care centers for free. HealthMap, a national project run by Boston Children’s Hospital in combination with the Harvard Medical School and the CDC, is a web site – vaccinefinder.org/find-vaccine – that allows users to find where to be vaccinated against a number of illnesses; a search for providers of flu vaccine suitable for adults 18 years of age or older within 10 miles of ZIP code 02909 in Providence (chosen because it is a known COVID-19 hotspot) returned 115 results. The website allows fine-grained searches, such as locating egg-free vaccines for those with severe allergy.

RIDoH and CDC recommend seasonal flu vaccine for everyone age 6 months or older, unless they have a specific allergy or other unusual medical condition (such as a history of Guillain-Barré syndrome) that precludes it. The US Department of Health and Human Services (HHS) on August 19 issued an emergency directive allowing pharmacists to administer vaccines to children aged 3 to 18. Wendelken of RIDoH told Motif, “Rhode Island pharmacies already have authorization to vaccinate children down to age 9. The HHS declaration allows pharmacies to vaccinate children as young as 3, so they can vaccinate if they want to. At this point, we’re not sure who will.” RIDoH has an active childhood vaccination program with information for parents.

It takes about two weeks after vaccination to achieve full immunity, so it is best to be vaccinated beginning in mid-September but doing so even months later is still beneficial and worthwhile. In a typical flu season, which (in the Northern Hemisphere) runs September to April but peaks December to February, less than half of Americans choose to be vaccinated, despite widespread availability. Wendelken said in RI usually roughly 78% of children between 6 months and 17 years are vaccinated, but only 56% of adults 18 years and older are. In recent years, RI has been one of the states with the best childhood vaccination rates, and only recently made a substantial recovery from a huge drop during April and May due to COVID-19 stay-at-home orders and closure of many health care providers. Wendelken said RI ordered 29% more doses of flu vaccine this year than normal, about 683,000 instead of 530,000. “We are going to be doing more outreach to community partners to set up community located flu clinics this year, and we envision having flu shots available at COVID-19 testing sites for asymptomatic people.”

While COVID-19 is much deadlier (see motifri.com/covid-death-rate sidebar), seasonal flu is a major public health threat in its own right. The CDC retrospectively estimated that the relatively mild 2019-2020 flu season resulted in 24,000-62,000 deaths, 410,000-740,000 hospitalizations, 18-26 million medical visits, and 39-56 million infections out of a US population about 330 million. Wendelken said that RI had 1,300 flu-associated hospitalizations during the 2018-2019 flu season, although the 2019-2020 season “was very abnormal because we were encouraging people to not go directly to healthcare facilities unless it was an emergency.”

Many avoid the flu vaccine because they are either under the mistaken impression that “just the flu” would not be so bad, or they believe misinformation about the vaccine itself. The CDC publishes common questions and answers trying to combat such wrong beliefs, explaining that the vaccine cannot cause the flu (“The vaccines either contain inactivated virus, meaning the viruses are no longer infectious, or a particle designed to look like a flu virus to your immune system” and “Side effects of the flu vaccine are generally mild and go away on their own within a few days”). Single-dose packages of flu vaccine do not contain thimerosal, a preservative with ethylmercury, which in any case is different from methylmercury that is of concern for mercury poisoning. Another misconception is that a vaccine is pointless if it is deemed, for example, “only” 60% effective: but that actually means someone vaccinated is almost three times less likely to be infected.

While the flu often is not a severe illness for most people, it can still be debilitating: heightened strict rules due to COVID-19 require anyone with flu or flu-like symptoms to stay home from work or school and isolate in quarantine for about two weeks; the era of going to work or school while sick is over, and doing so while previously regarded as muddling through with a strong work ethic is now understood to be dangerous to others. For essentially the same sub-populations at high risk from COVID-19 – healthcare workers, first responders, pregnant women, those 65 or older, or with underlying health conditions – the risk of bad outcomes from seasonal flu is greater and therefore being vaccinated is especially recommended. Guidance from WHO and RIDoH also considers anyone who lives with or is a caregiver for someone at medically high risk to be strongly recommended for vaccination.

Asked by Motif whether there would be conflict in scheduling production resources between seasonal flu vaccine and an eventual COVID-19 vaccine, WHO responded, “Since March influenza activity is historic low. The predominant virus strains of this coming winter are yet to be seen. WHO will issue recommendation in September on viruses to be included in vaccines for Southern Hemisphere 2021 season [March-October]. Seasonal vaccines are always ordered in advance. We know that [there is] more demand for the upcoming season and manufacturers are meeting the demands. Production platforms for influenza and COVID-19 vaccines are different, therefore negative impact from COVID vaccine development is less likely.”

COVID-19 Is Not Just the Flu

How deadly is COVID-19? How does it compare to seasonal flu? These are difficult and controversial questions.

Above all, it should be emphasized that some sub-populations are definitely at much higher risk for bad outcomes if they become infected, such as people with compromised immune systems due to existing underlying illness or simply old age. It should also be understood that some patients are extremely unlucky even if they are part of an otherwise low-risk sub-population, such as young people who contract rare multisystem inflammatory syndrome in children (MIS-C) that appears to be correlated with COVID-19 in ways that are not yet understood.

Speaking in terms of broadly aggregated data, however, it is possible eight months into the pandemic to draw some conclusions based upon actual measurements, even if the measurements themselves and the resulting conclusions have large uncertainties. The US Centers for Disease Control and Prevention (CDC) on July 10 switched from reporting case-fatality rates (CFR) to infection-fatality rates (IFR): setting aside whether this was the result of political pressure, in general the difference is that the CFR is based upon cases diagnosed while the IFR is based upon cases both diagnosed and undiagnosed. In the context of COVID-19, this is important because people who have either no symptoms or such mild symptoms that they do not even know they are infected count in the IFR but not the CFR calculation. Obviously, it is very difficult to count undiagnosed cases, so estimating them depends upon trying to measure what proportion of infections are so mild as to go unnoticed and extrapolate from surveillance testing of people without symptoms.

The CDC performs meta-analysis on data and studies, resulting in several scenarios that they think are most likely to represent reality. Unfortunately, their estimate of undiagnosed (asymptomatic) cases ranges as low as 10% to as high as 70% with a “best estimate” of 40% of total cases, an enormous amount of variation. The larger one believes the number of undiagnosed cases to be, the lower the IFR for a given number of deaths as a purely mathematical consequence.

On the other side of the fraction line, one would think counting deaths would be easy, but it’s not. The CDC counts COVID-19 fatalities weekly, although delays in reporting from a multitude of local jurisdictions with widely varying clerical practices and resources can introduce weeks of delay, but as of August 22 their number was 164,280. Despite its faults, this is the best hard number available; it’s a lower bound.

There is the matter of definition: What is a COVID-19 related death? The CDC has clear rules on that, but again there is room for disagreement on their appropriateness. Certainly if you test positive for COVID-19 and die of acute respiratory distress syndrome (ARDS), gasping for breath on a mechanical ventilator, everyone would agree to attribute your death to COVID-19. But what if you test positive for COVID-19 and die of something else that is plausibly related to COVID-19, such as a heart attack or ischemic stroke that you probably would not have had but for the stress on your body of fighting COVID-19? What if you died from a heart attack or stroke, although you’re not infected by COVID-19, but you decided not to go to the hospital because you were afraid of COVID-19? What if you had symptoms of COVID-19 but chose to stay at home, were never tested nor treated, and died there?

One way to capture this complexity is to look at the number of “excess deaths,” the number of deaths above what would have been statistically expected based upon past experience. For the week ending April 18, the US had about 38% more deaths than expected, 77,086 instead of the expected 55,683. That was a very bad week, but the concept encapsulates the key idea: How many people died that week who would not have died without the pandemic? As a practical matter, this is what the ordinary person means when they ask that original question: How deadly is COVID-19? How many deaths are we under-counting?

But excess deaths is too broad a category for public health experts to use for effective planning. What they want to know is not “How many people died because of COVID-19?” but rather “How many people died because they were infected with COVID-19?” This is where those previously mentioned hypothetical CDC scenarios come into play, with the IFR between 0.5% and 0.8%, and a “best estimate” of 0.65%. These IFR numbers may seem low, but this is merely a mathematical consequence of the number of undiagnosed cases being high.

And the United States is very big. How big? The total population is about 330 million, so that 0.65% IFR implies, if 100% became infected then the death toll would be over 2.1 million people! That is presumably a worst-case upper-bound scenario: If physical distancing, mask wearing, hand-washing, and other methods prevent infection in the first place, that would save a lot of lives, possibly millions of lives, and delay the spread of the virus until a vaccine can be made and distributed.

As I write this in the late afternoon of August 27, the CDC data release at 4pm today estimates a cumulative total through yesterday of 5,799,046 diagnosed cases, of which 46,393 new cases occurred yesterday, and a cumulative total through yesterday of 178,998 deaths, of which 1,239 new deaths occurred yesterday. Seasonal flu was not killing well over a thousand Americans daily. By the way, that works out to a CFR of 3.1% in the US, which might be why the CDC was under pressure to replace it with the more speculative IFR. A CFR about 3.1% would put COVID-19 into the same league as the 1918 pandemic that killed 50-100 million worldwide: contrary to intuitive expectation, a virus in order to continue to spread to kill a maximum number has to avoid killing its hosts too effectively, and 3% seems to be the sweet spot. The widely respected COVID-19 tracker at Johns Hopkins University currently shows 24,284,974 cases and 828,041 deaths worldwide, a CFR of 3.4%; among all countries the US is in the dubious first place in both categories, well ahead of second-place Brazil.

COVID-19 new US cases per day, as of August 27, 2020.
(Source: CDC https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html)

How much worse is COVID-19 than seasonal flu? In the October 2019 to April 2020 flu season, there were 24,000-62,000 deaths from 39-56 million symptomatic infections, implying a CFR of 0.1%, roughly 30 times lower than the 3.1% of COVID-19. But people have residual immunity to seasonal flu from prior exposure to similar strains, there is a vaccine that about half of adults get, and there are proven treatments for those infected – none of which is true of COVID-19 – so the spread of seasonal flu is inherently limited.

If your COVID-19 is bad enough to put you in the hospital, outcomes grow quickly much worse: 11.7% of hospitalized patients age 11-49, 21.8% age 50-64, and 21.3% age 65 or above will need a mechanical ventilator; 2.0% of hospitalized patients age 18-49, 9.8% age 50-64, and 28.1% age 65 or above will die. Well, that escalated quickly. So what are your chances of needing to be hospitalized? We know that from COVID-NET: as of the week ending August 15, 102.2 per 100,000 population age 18-49, 228.1 age 50-64, and 412.9 age 65 or more – so far.

None of this should be misunderstood as hopeless doom and gloom: instead, understanding the severity of COVID-19 should emphasize the critical importance of acting responsibly to observe public health recommendations proven to work: isolating if symptomatic, physical distancing, mask wearing, hand-washing, avoiding crowds. With more than 1,200 Americans dying daily, no one should mistake the virus for being under control, but we do know how to bring it under control.