Ruth Werner, author of A Massage Therapist’s Guide to Pathology, discusses her recent article “What Will It Look Like When We Go Back to Work?” Werner gives an update on COVID research, testing, and weighs the risks vs. benefits of reopening practices.
This episode is sponsored by ABMP.
00:01 Darren Buford: Our gift to you, weekly free CE from ABMP as a way to give back to the profession during this challenging time of COVID-19. ABMP is offering free access and CE for five courses in the ABMP Education Center each week for four weeks through May 6th. Simply register online at abmp.com/ce for access to watch these video-based courses, which are among the 200-plus available to all ABMP members in the ABMP Education Center. Please enjoy these courses and free CE while we look forward to resuming practice.
00:45 DB: Welcome to Conversations in Quarantine. My name is Darren Buford, and I'm the editor-in-chief of Massage & Bodywork magazine, and Senior Director of Communications for ABMP. Our goal here is to speak with luminaries and experts in and around the massage profession, to talk about the effect of COVID-19 on bodywork practitioners, the fears, the frustrations, and more importantly to discuss next steps towards safely reopening our doors when the time is right. How to pivot now, how to prepare for the future, and discussing what the new normal might be. My guest today is Ruth Werner. Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote "A Massage Therapist's Guide to Pathology," now in its seventh edition, which is used in massage schools worldwide. Ruth is also a long-time Massage & Bodywork writer, most notably of the pathology perspectives column. And she is the cover feature in our May, June 2020 issue on endangerment sites. Ruth is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Ruth's books are available at booksofdiscovery.com. And more information about Ruth is available at ruthwerner.com.
01:58 DB: Hello, friend. How are you doing?
02:00 Ruth Werner: I'm well, Darren. How are you?
02:02 DB: Good, good. I wanna start by talking about your excellence article that you wrote, "What Will It Look Like When We Go Back To Work?" If you're listening to this and you have not read that, stop. Because a lot of this, a lot of our conversation, while it may be applicable in the listening forum, you really are gonna get a better depth of this conversation if you have read that piece. So, saying that, I love the article, and we put it in our COVID-19 special issue of Massage & Bodywork, which is available at abmp.com. It certainly woke up a lot of the profession to the realities of what it might look like moving forward. How are you feeling about any of the feedback that you've received in the past two weeks regarding that?
02:51 RW: I'm feeling extremely compassionate that so much of our profession is in such a difficult position right now. And one of the comments I read on the article was, "Yeah, easy for her to talk, she's not in practice," which is true. And my heart really goes out to the people who are trying to figure out a way to get back to work partly because of financial stressors, but partly because people are drawn to this profession when they have a drive to make the world a better place, and it just seems like our work is so called for. And as you and I have talked about, there's this tremendous tension between, "I gotta get back to work. I have to do the work that I am here to do on the planet," and, "I have to keep people safe at the same time." And so people like me, and I'm certainly not the only one, who have come forward to say, "Hang on just a second, let's think this through before we make any big decisions," we're hearing from people on both sides of that struggle all the time, and it is a little heartbreaking because all we want is to be able to do our work, and to do it safely.
04:08 DB: When we spoke briefly before this, I mentioned that, at ABMP, and I know you're seeing this in a lot of massage forums, you're seeing two groups. You're seeing the reopening group, and you're seeing a safety group. And those two are fighting each other a little bit, and I don't mean people, I mean those thoughts, per se. I knew you warn the profession and your piece about prematurely reopening. And we're already seeing challenges to that in various states that are beginning to open, and within the next week, maybe two weeks, we'll be lifting some of those stay-at-home sanctions. You're hearing the contingent that, "We can't wait for herd immunity, and we can't wait for a vaccine, and we can't wait for an antibody test. We need to open now." And you would ask for pushing a pause button in your article. Has anything changed in your thoughts with regards to what we've learned about the disease's progress or in our own profession in the past couple of weeks that would change any of the ways that you think with what you've put in the piece?
05:13 RW: COVID is such a quickly moving target, and we learn things. I'm learning things every single day that continue to color my attitudes about this. And so one of the things I called for in the article, that I still call for, is fast and accurate testing. And in the article, I talk about the difference between testing for whether you have the infection currently, symptomatic or not, and the other part of that is to see if there's evidence of someone having already been through the infection, symptomatic or not, and that would be the serum antibody test. One of the developments just over this weekend has been that that serum antibody test A is not simple. We're still trying to develop a good one. Even though there are tests being distributed now, there's no overall governing body that says, "This test is accurate, this test is not."
06:15 RW: But also there is evidence that, for some people, infection does not impart immunity. And so to say, "Yeah, I've had the infection, I'm no longer a risk to anybody," may not be true, and that's really, really bad news. It impacts our understanding of where the line for safety is. And although I have not yet seen, because it's early on a Monday morning, I have not yet seen articles that mesh that information about resistance to developing immunity and the capacity then of developing a vaccine. I don't know if those two things are in conflict with each other. I just keep coming back to that. This is a moving target. And I had hoped, when I wrote the article, and there was reason to believe that it might work out that way, that a single infection would impart immunity to most people. And that turns out maybe, maybe not to be true. Because we're seeing things about people having to go back to the hospital after they've been discharged. We're seeing people who are being tested as positive after they had tested as negative.
07:34 RW: That may be a reflection of tests that aren't that accurate, but I'd like to take a minute and talk about maybe yeses. I can see situations in which massage therapy might be delivered to people who really, really need it in a setting where it is as safe as it is possible to make it at this moment. And ironically, I envision that... In my understanding of our profession, I envision that happening most easily in hospital settings, because the expectation is for disinfection and extremely close attention to hygiene. For massage therapists who are in the hospital system, who have access to personal protective equipment, who are working with patients who are under medical surveillance, it seems clear to me that that's probably as safe as other nursing interventions that people get. The caveat is we must not be taking personal protective equipment away from frontline workers who need it for people who are dealing with active and communicable infections. And I wanna be really, really clear about that.
08:55 RW: And a realization I had a few days ago is if PPE, personal protective equipment, had been available and not in such short supply, and had been available to everybody, including massage therapists, but with no shortage for primary care providers, our whole interaction with this infection might have looked quite different. Because I could see someone in a massage office, say, working with a mask on, working with gloves on, working with a top that they can change with every client. I could even see, when a client is face up, asking them to wear a mask, and we can talk about that a little bit more if you like. I can see maybe not doing head and face work for a while, at least with a client prone, until infection rates have dropped more. I can see some of those opportunities if, and only if, personal protective equipment that's effective and used correctly is available to everybody, and by our purchasing it we are not taking it away from someone who needs it way, way more than we do.
10:08 DB: Because of the backlog that we're still seeing with regards to PPE, even in our hospitals, you're seeing makeshift equipment that a lot of frontline responders are using.
10:22 RW: Garbage bags.
10:23 DB: Garbage bags, yes.
10:25 RW: Rain ponchos from baseball games.
10:29 DB: Absolutely.
10:30 RW: And it's not okay. It is not okay.
10:32 DB: So, my next question is definitely going to be... There are going to be practitioners who are able by their state laws, who can practice or will be able to soon, but who will not get access to PPE for quite some time. And that same makeshift thought, I'm sure, is gonna go through many people's minds about cloth masks practicing or hygiene potentially not up to the standards that we may need to get to. And I'm imagining your words for those people or... I don't wanna put words in your mouth, but you're probably suggesting, "Don't do that." Right?
11:16 RW: Well, I really work hard not to have to say, "Don't do that." Weigh risks and benefits. Right now, COVID-19 has a transmission rate with no social distancing, where a person who has the virus, symptomatic or not, is likely to infect somewhere between three and six other people. Our new diagnostic rates... No, not even diagnostic rate. Our new infection rates will not go down until that transmission gets down below one. So, a person who's infected will only infect one other person. And we achieve that through... I don't like the word "social distancing" because we can be socially very close. But we achieve that through physical distancing, and good hygienic practice, and if possible the creation and institution of a safe and effective vaccine. If we are using a gesture in the direction of protective equipment that is not actually protective and not actually effective, what we're engaging in is theater that makes people feel better but that does not actually achieve its intended result.
12:41 RW: I have a hard time envisioning massage therapists putting a garbage... Cutting a hole in a garbage bag for their head to go through, and then wrapping that around themselves, and using hardware store rubber gloves and a cloth mask and calling that a usable... And then switching those out for every client, and calling that a usable solution to this problem.
13:09 DB: One of the things that we've talked about, and you mentioned it, is there's safety and then there's the perception of safety. Both are important.
13:19 RW: Yes. Yes.
13:20 DB: That will be part of practitioners feeling safe to practice again, but also clients willing to come back. And there'll be many steps, I would imagine, in the process. Proper hygiene is one of those, the PPE potentially is one of those as well, but there may be some hurdles to getting to that. Although I am hearing numerous people with practitioners who are ready to practice right now and clients who are ready to go back, or through the practitioners saying to us that we're not speaking directly to clients, that are willing to go back right now because their massage is needed and/or medical, and/or essential. I wanna shift a little bit here because... Can you tell me a little bit... I know people have heard about this because of the Spanish flu epidemic, but can you tell me a little bit about second and third wave spread?
14:09 RW: Here's what we can expect, because we have seen this in the past, is infection rates will begin to go down. Death rates, please God, will begin to go down. And then businesses begin to open up, and the physical distancing begins to subside, and then there is a new wave and sometimes more than one new wave of new infections. And we're seeing that in several Asian countries right now, where they thought it was really under control and they... We all congratulated them on doing a great job, and they began to open up again, and now they are hit with another wave. I think we can anticipate this, this is going to happen. But if we are smart about it, and by we I mean not just massage therapists but our systems in this country, we can anticipate this and be ready for it. One of the things that I have watched with interest, partly because I have some connections with the massage therapy community there, is what's happening in New Zealand. And they just, this week, in fact today... Monday is the day that they're lift... They're going from a level four shutdown alert to a level three, and they've defined specifically what that is. But they're doing it for two weeks, and then they will re-evaluate to see if they need to go back to level four. And everybody knows. And I think that is so wise.
15:37 RW: There is some guidance from the World Health Organization and from the CDC about steps that it will take to reopen, and built in with those steps is the ability to go backwards. We need to be nimble and ready to... While people wanna get back to work, and that's good for lots and lots of reasons, we also need to be ready to say, "Okay. I tried it and now we know that we need to wait another couple of weeks, or another however long," please don't quote me on anything about periods of time. But I think we need to anticipate that stop-start a little bit, because it is in the nature of how pathogens move through communities that we will see a subsidence, and then it will probably peak again.
16:30 DB: I know that you've been working with the New Zealand massage therapy group with regards to what coming back to practice might look like. And that was really interesting for me to hear you say that the government is implementing a step where there's a level four, to a level three that might go back to a level four. Now, I don't mean anything with regards to that level of government intervention. I mean something more of local groups. Is there anything in the United States that you're seeing right now with various people who are trying to put together what it means to come back to practice, whether that means hygiene, whether that means this is the outlet and this is how we get PPE, or this is how we make ourselves essential and part of the conversation? Is there anything you're hearing out there with regards to this is what it might look like in next steps?
17:21 RW: I think it's fair for massage therapists and, even better, communities of massage therapists to think about what they want in order to feel safe to open their practice again. And that really was the point of my article, is like, "What should you be thinking about in terms of parameters for safety?" And I'm seeing more and more people in discussions about that, and a lot of what I wrote came out of conversations that I was invited to participate in as well. So, availability of PPE, without taking it away from people who really need it, is one thing. Availability of cleaning products... Because that's another thing I've seen turn up, is people are talking about how they can't get rice and beans at the grocery store, but you know what else you can't get, is good cleaning product. And so that's another... We cannot think about opening our practice if you can't have a reliable resource for, I'm gonna go out on a limb and say, FDA-approved disinfectants. And there is... Among the resources, and I can give it to you to go with the show notes for this, if you like, but it's in the resources that are in the article, is a list of FDA-approved disinfectants. So, those are things to make sure that we have in place.
18:41 RW: But I'm also seeing people talk about putting, writing in disclaimers, or writing in some kind of hold harmless agreements between massage therapists and clients, so that if a client feels they have carried home a new infection from the massage therapy office, that therapist won't be hammered or held liable. And we might think about reversing that as well, that massage therapists will hold clients harmless if they feel they have been exposed. I don't know if anyone is really willing to do that. I hear stories all the time. All the time. I had two in my inbox today about clients who come in and say, "Oh, no, I'm not sick. Really it's just allergies." And they're coughing, and hacking, and sneezing. And three days later, the massage therapist is down with a cold. If you were a client, would you sign away your protection from being responsible for somebody's illness? It's a very, very complicated thing.
19:48 RW: Add to that the idea that people will be able to turn people away from receiving massage if they feel like it's a bad idea. That gets really complicated. And that's a place where I think the State Board for states that are lucky enough to have a license. I think the State Boards are gonna have to take an authoritarian point of view to say, "Here are the limits on what you can and cannot do in terms of saying yes or no to your clients." I say this over and over again, and I apologize if it's repetitive, but I have been around long enough to remember what it was like when massage therapists were faced with decisions about working with clients who were HIV-positive. There was a lot of fear, and there was a lot of concern, and there was... And it wasn't until we could really conclusively demonstrate that HIV and hepatitis B and C are not spread easily through casual contact. And so discriminating against clients or saying "no" to clients who are positive for those infections became an illegal discrimination.
20:58 RW: That's not true for COVID-19. This is easily spread through very casual contact. And so the day may come when massage therapists have to decide, "Am I gonna work with you? Am I not gonna work with you? What is the basis on which I make that decision? And am I applying that equally to every client? And if I don't, is that legal?" And I think that, I don't know if the State Boards are even thinking about this yet, but they have to because that's where the clash between safety and the law come into play. Really, there are no simple answers. And until we know more about immunity, and antibodies, and vaccines, it's gonna be really hard to provide guidance. And yet, I think, more than the organizations, more than people like me who are well-informed and happy to share information, the State Boards are the ones who really... The buck stops there.
22:08 DB: Can I circle back really quickly to the PPE discussion, because I know that you've been a proponent for uniforms that an MT, or a practitioner, a bodyworker, might use and might change between clients. Now, that would definitely be something new. I don't think practitioners have thought of that. They may have gone down the PPE path, but they might not have thought about what does that mean between clients.
22:33 RW: Simpler than trying to buy and use a bunch of paper hospital gowns would be to have six work shirts. And all you have to do is change your shirt and throw it in the laundry with the rest of your laundry. And if you don't wanna do shirts, do aprons. And this is something... Well, when I was in practice, that's what I did. I didn't feel good about having people's arms up against my shirt, not because of the oil stains, 'cause I didn't really care about that, but because I was trying to create in my session room a place where nothing that one person touched would be touched by another person unless it was cleaned or changed in the meantime. And so I bought a bunch of aprons, and I would just take off my apron and throw it in the laundry with the rest of my laundry. And that all gets done in the same way.
23:24 RW: For what it's worth, one of the things we do understand about COVID, and I have not seen change yet, is that it is vulnerable to heat and soap, and so we don't have to do extra bleach, we don't have to do anything different with our laundry. If we're using basic, OSHA-approved standards for doing laundry, we're gonna be fine in terms of controlling the virus on our fabrics. I've seen people say, "I can't possibly change my clothes between every client." Well, you don't have to change all your clothes, you have to change the parts of your clothing that clients touched. And that means an apron or a work shirt. And if you are gonna try and go back into practice, and you cannot afford six work shirts to get through your day, I'm sorry, but it's time to re-evaluate how you're investing your work money because that's just a... I will probably get flak for that, but to me that's a baseline easy way to accomplish that goal of fixing it so that a client does not touch anything that another client has touched.
24:35 DB: We haven't touched on it here, but you mentioned there just the ramifications potentially financially of PPE, increased cleaning products, and increased standards. Those are maybe things that massage practitioners that's gonna be the new part of doing business that hasn't...
24:53 RW: Also increased turnover time, because the... I said this in the article, I think the 10-minute turnover might not stay with us, and that means maybe one fewer appointment every day.
25:08 DB: I don't necessarily know... Obviously I don't know what the ramifications of that might be, but there is the possibility that there could be increased cost of doing business, and then either absorbing that cost or passing that cost on to our clients. Now, personally, I would imagine that most clients would be okay with that because once we come out of this there's gonna be an understanding. I don't have an answer for that, but it was one of the things I keep thinking about with regards to new practice. There are so many ramifications that we haven't thought of yet, we're just at step one. And once we actually are practicing again, there'll be nuances that we haven't thought of, and those will be new conversations and new flexibilities that we'll have to adjust to.
25:49 RW: Yeah. And I think we will be able to get great client, literally client buy-in on this because it really is a demonstration of our care for their well-being. And I've seen therapists talk about, "I'm gonna have my clients come in and use hand sanitizer, and we'll all just sanitize our hands together," and little things like that that demonstrate... Again, it's theater, but this is theater that is effective. It's demonstrating some effective practices. But I think it's a way we can engage people in our care of them that could be really helpful and, I think, strengthening to the profession.
26:31 DB: If you don't mind, let's transition just a second. We've got some reader questions, and I got a couple here that I'd like to ask you. This is from Anonymous, I don't know who the source is. "We know that these viruses mutate every year and vaccines won't protect you from mutated strains. Will it become an annual thing like the flu shot?"
26:51 RW: Yeah, I hope so. I was listening to a very interesting podcast the other day that was mostly about Dr. Fauci, who is the head of the National Institutes of Allergies and Infectious Disease. And probably most of our listeners have heard his name because he's our national authority figure on this. And he has proposed, in his history as a researcher and infectious disease specialist, the idea of creating essentially vaccine platforms that can then be built on year by year, depending on what's present, so we don't have to reinvent the wheel every single year. The mutation rate for COVID, they think there might be three strands right now... Or three strains, I should say, right now. But given its infectious rate and how quickly it has moved around the world, I'm not sure how quickly or how easily it mutates.
27:51 RW: And one of the nice things about viruses that mutate, and this is what we saw with the Spanish flu, is that they can just basically mutate themselves out of existence. That's one of the ways that viruses burn themselves out. Vaccines are a difficult topic, and I think that's a place where our profession is really, really going to struggle. And in the article, I said, "You're gonna have to have a policy about vaccines for yourself. You might have to think about a policy about vaccines for clients. I'm not saying what that policy should be, but you should think about it thoroughly and have a good rationale for the decisions that you make."
28:35 DB: Let's transition through our last one here. "When I first suspended my practice, I was thinking I would not work on people for two weeks after they have been traveling once I reopened. Do you think this might be a good policy to add just in general because who knows what else might be lurking out there?"
28:50 RW: It's an interesting question. I think it would be an interesting question to ask at least for a year or so after this particular dust settles. Not necessarily to say, "If you had been traveling out of the country, I won't work with you," but, "If you've been traveling out of the country, tell me where that was. Let me quickly check what the risks are associated with that part of the world." And I would add to that, and someone... I had a conversation with someone earlier today via email on this topic who was updating her intake sheet. She had a question about travel. I suggested an additional question about nursing homes in the United States. And again, this is something that has really, really... It's not new, but it has risen to people's consciousness in the past week, that nursing homes are the hot spot, the hot spot for new and uncontrolled infections. And so I would be concerned to... I would have concerns on behalf of someone who had been visiting a nursing home within the past couple of weeks. That's a place where the virus is really, really active, and is being undercounted, and really not adequately dealt with.
30:13 DB: It could change... It will change the intake process with regards to... Because I know that this question was probably asked with regards to traveling internationally. But right now, if you're able to practice, it would be, "What hot zones have you been in?" Or, "Have you've been in anywhere near these cities?" And those flare-ups could change over the next month, two months, six months, as we progress down this path, but the intake process could be very critical here. And again, that goes back to what we talked about earlier about the right to refuse service.
30:49 RW: Yeah. And I was interested in the temperature taking as well. You can make an argument that that's in our scope of practice, especially if it's not in the mouth thing, if it's like a forehead tape kind of thing. And that is a practice that a lot of the countries that managed COVID-19 well did early, taking people's temps when they got off the airplane, when they entered public buildings, whatever. By the time someone has a fever, they are sick. But at least that gives you the ability to say, "Oh, no, we're gonna sequester you now. And by the way, who are all the people you've been in contact with in the last two weeks?"
31:29 DB: Last question, Ruth Werner, "What can you say to massage therapists to put them at ease about their professional futures in this work that they love?"
31:39 RW: I don't know if I can say anything to put people at ease, 'cause that's not where we are. That would be false. What I can say is, do your best to hang on because we need you. We have never needed massage more than now. I know that this whole event will end the careers of some people, and it's heartbreaking, but I hope it doesn't end yours. And I hope that you can find a way to adjust, and to get to yes safely, and to work with your organization, with your State Board, with your cohorts cooperatively and in a really sensible and evidence-informed way. Look for the helpers. We're all trying to help each other. I can't put you at ease, but I can encourage you to hold on and be ready to have a big party when that is a safe thing to do.
32:42 DB: I am ready for the big party with a massage. Thank you so much, Ruth Werner, for joining us today in Conversations in Quarantine.
32:49 RW: Thanks, Darren.
32:50 DB: And if you would like to check out more information about Ruth, it's available at booksofdiscovery.com, and ruthwerner.com. Thank you, friend.
32:58 RW: Thank you, Darren. Take care.