Tuesday 19 May 2020

Fear and Loathing,.. But Mostly Fear

Fear? Who, Me?
I began talking about the SARS-CoV-2 pandemic with my students this past January as news of what was unfolding in Wuhan, China emerged in newspapers. I noted the many table-top exercises I had read about in which very knowledgable people in those simulations made poor decisions or confronted major gaps in preparedness. I also noted the macabre decisions that were made, for example, in aftermath of an attack from a bioweapon, and how ill-prepared our health systems were for the 2003 SARS-CoV-1 event which killed less than a thousand people around the world.

However, I also told students that one of the things I personally worried most about in the context of pandemic or bioweapon responses was them; not their personal health and safety, but their collective responses to what was going on.

I shouldn't be surprised at the level of fear this has all generated, but I am.


Started With TP

In the weeks before lockdowns were ordered for large swaths of the world's population in March, we all noticed the dwindling supply of toilet paper on store shelves. Most of us laughed at the folly of stockpiling toilet paper, created memes about the irrationality of it all, even puzzled at the serious psychological analyses about the behaviour in newspapers. However, as many of us bought more toilet paper, others of us stood in line and quietly asked ourselves whether the hoarders knew something we didn't? 

Fast forward a month. Now our grocery store visits are an ever-evolving, Byzantine mix of sanitizing stations at doorways (some of which mostly remind me of what I've seen in most airplane washrooms), crowd control roping, bouncers with tally-counters, masks, one way aisles that not everyone understands, arrows on floors, bans on reusable bags, and cash people I can no longer hear because they're behind plexiglass. 

All Too Familiar
However, what bothers me most about all of this is the palpable fear among my fellow humans. I can deal with all of these social-distancing measures for a while; steering a wide-path while walking, keeping my distance while in line, etc. I've never been a fan of big crowds, so I've done a lot of this for a long time. For instance, I don't want grandma thinking I'm trying to steal their PIN number at the grocery store, so I tend to give people some breathing space. Yet, I have more than once recently exited a grocery aisle and come face to face with another human. The horror behind their mask at seeing me is obvious.... and irrational.

Unfortunately, there's a large body of academic literature about how well humans reason (anything by Herbert Simon is a good place to start). It's not a pretty picture. Of note is our inability (or unwillingness) to quickly change our views on things when presented with evidence to the contrary. Our cognitive confirmation biases are among the major challenges we confront in knocking down the many conspiracy theories circulating on social media. 

Coronavirus News Network

Back From the Dead
If there was ever a news event perfectly tailored for the sensationalism of 24-hour cable news, SARS-Co-V-2 was it. It's a gift to fear-mongering. We are all confined to our houses with nothing to do but watch the latest "expert" (also largely confined to their houses) pontificate about all the reasons we are doomed. The CNN death-ticker frequently takes up a third of my television screen. Anchor Chris Cuomo actually became quite ill with covid-19, but continued to broadcast from his basement bunker. There was even an episode dedicated to his post-symptom emergence from his bunker, after which he went back to his bunker to continue doing his show.

CNN has also been great at giving exaggerated (in my view) attention to victims of covid-19 who are statistical outliers; profiles of victims in their 30s and 40s, or more recently the very young exhibiting symptoms of Kawasaki Disease which some doctors think MAY be connected to SARS-CoV-2. I consume more news than I should. Where are all the human interest stories about the overwhelming majority of people who recovered with few complications? Why does it seem as though the only people the media are interested in are those who nearly died?

Not Helpful
I'm also deeply frustrated by the litany of writers who are predicting a grim, nearly post-apocalyptic future as human beings now that SARS-CoV-2 is with us. Yesterday's Globe and Mail was a real treat. The headline: "46 Ways in Which Our World is About to Change." Good gawd. It might as well say 46 ways in which our humanity is going to be taken from us. And really? There have been societal changes after every single previous pandemic, but nothing especially revolutionary. Why is this any different? Are we being subjected to this kind of fear-mongering so struggling media outlets can boost sales? Or do they really think they're doing everyone a public service by preparing them to be even more fearful of an uncertain future than they already are?

Get Thee to A Bunker?

It doesn't surprise me that SARS-CoV-2 has become another political football in our polarized political environment. But it does depress me. It's become yet another issue for partisan bickering which oversimplifies complex issues into mindless sound-bites that make it seem as though we have only two choices before us in dealing with coronavirus; 1) open up the economy and kill grandma or 2) stay hunkered down and kill the economy.

Good grief.


The media have conveniently played into this polarization, mostly offering what their respective viewerships want to hear. But anyone with a shred of insight understands that few things in life are purely binary choices. Just because you are worried about your economic survival and/or mental health because of the lock-down measures does not mean you are an anti-science, MAGA-hat wearing, luddite who thinks SARS-CoV-2 is a deep state hoax to unseat Donald Trump. Similarly, putting your health and that of your family at the top of your priority list does not mean you are an out of touch elitist with a cushy white-collar job that allows you to continue working, home school your kids, or go to your summer house to avoid the contagion in the cities. 

SARS-CoV-2 is real and deserves our attention and respect as we learn more about it. So too, however, are the consequences of our response. In my view, too little attention has yet been devoted to the host of socio-economic, generational, gender-, and race-based impacts of SARS-CoV-2.

They are hardly secondary because they, perhaps like the coronavirus itself, are going to be with us for a very long time. 

Public Health Stats... or Lack Thereof

Mark Twain succinctly popularized a now-commonplace take on the frustration with statistics writing that "There are three kinds of lies: lies, damned lies, and statistics." Statistics are powerful in shaping our perceptions and decision-making. However, data seldom speak for themselves. They require careful contextualization and interpretation, particularly so given the human propensity for poor reasoning.

I'm not a statistician, but I routinely see distortions in the statistical evidence depicted in the press and am troubled by the fear it's all generated. 
Wage Subsidy Running Out

One basic problem is that cross-country comparisons of covid-19 statistics is nearly impossible because of the variance in how countries even count them. Indeed, coming to grips with the true impact of SARS-CoV-2 is difficult because of data gathering differences within countries as well. Critics of the U.S. response have noted this problem, but it's also a problem in Canada. There's been important reporting on how the last several months represent a significant statistical spike in excess mortality. However, turning to these numbers seems mostly driven by the cross-country variance in other data sources.

If responsibly loosening lockdowns is a short-term goal, alleviating the public's fears about being around others is going to be essential.

I'm torn between blaming our political leadership or our public health authorities, but in my mind it's a dereliction of responsibility and a fear-generating problem that will make everyone's job harder as we try and convince people to return to some semblance of normalcy over the coming months. 

Critical Denominators

One of the reasons governments have imposed blanket lockdowns is that lockdowns are all they have to work with. While there's been some nuance among countries in how lockdowns have been imposed (some doing more tracing than others, etc), there's very little nuance in the basic idea that lockdowns are the best strategy we've got (except for Sweden, of course). It strikes me as a blunt instrument applied after it was already too late, and may yet turn out to have been the wrong strategy given the collateral damage lockdowns have wreaked.

A strategy in which only sick people (or the well-connected) can be tested is flawed, particularly if a successful economic rebound is a goal. It's important to know what's going on with those who present as sick. But it's also important to know what's happening in the rest of the population, particularly among those who might be asymptomatic carriers. Importantly, we need not test entire populations to find out.

Where Did You Say I Could Get at Test?
With data only from those who've been tested, we have a distorted picture of the threat to the population. Even where large numbers of tests have been done, there's been precious little information about the bulk of people who recovered. The only people in that category meriting public attention seem to be those who nearly died or happened to be the British Prime Minister. Perhaps there are studies being done into those who presented at hospitals as ill, didn't qualify for a test, and then melted into the population to recover on their own. But I haven't seen them.

From those who are being tested, a number of important patterns have emerged suggesting a far more nuanced mitigation strategy that doesn't involve exploding the entire economy. For example, Canada's National Institute of Aging reports that more than 80% of Canada's covid-19 deaths have been in nursing homes. Population density and public transit seem to be obvious factors in why New York City has been hit very hard while less urbanized parts of the U.S. have not. In some ways, that pattern seems to have replicated itself in Canada. Dense population centres in Ontario and Quebec have high case loads. Less clear is why British Columbia (as of May 19) has just has just 2,444 cases (143 deaths) while Alberta has 6,683 (128 deaths). How can we explain such a gap?

Alberta claims one of the highest testing rates in North America, so it's out there hunting for cases. Yet, Vancouver has the highest population density in Canada at 5,400 people per sq/km and is also an international aviation gateway. By contrast, Calgary's population density is just 1,329 people per sq/km and Edmonton's 1,186 per sq/km, neither of which are major international gateways. Some appreciation of the case variance would go a long way to reassuring the public.

We've seen strong evidence that the poor or those who are in "essential industries," many of whom are minorities, have also been hit particularly hard by SARS-CoV-2. This certainly seems to be the case for Alberta's meatpacking industry, suggesting the need for unique mitigation techniques in particular facilities, not necessarily a province-wide shutdown.

Why aren't hospitalization rates more clearly articulated to the public? We are often told how many covid-19 patients are in local intensive care units, but less frequently informed of how many of those testing positive ever required hospitalization? In many places the expected wave of hospitalizations never quite materialized. In some locations, wings of hospitals set aside for covid-19 patients never saw a single patient. Have those jurisdictions been smart or mostly lucky?

We'll probably get lots of answers to these questions as scientists probe this pandemic for years to come. However, what people really want to know, and the key to successfully reopening the economy, is how likely they are to die if they leave their homes?

One useful statistic would be knowing the probability of death from infection with SARS-CoV-2,... not the death rate from positive covid-19 tests,.... We need the probability of death from a basic infection,...simple exposure to SARS-CoV-2, which includes asymptomatic or mildly-symptomatic carriers.

Giving us raw numbers of cases and deaths every day tells us little about the risk posed to ourselves and others if we go to the grocery store. Being told that between 4-6% of covid-19 cases are fatal  presents a distorted picture of what's going on since it only includes those who've qualified for a test; testing that varies considerably be country.

We already have several studies whose findings suggest exposure to SARS-CoV-2 is far more widespread than our limited testing regimes have thus far been able to detect, perhaps 50 to 85 times more. A 4-5% mortality rate just among relatively narrow set of people qualifying for tests, is a completely different statistic from a .05% mortality rate from a SARS-CoV-2 infection randomly sampled from a broader population.

Herd Mentality?

More disturbing than any skepticism about "herd immunity" is the "herd mentality" of many toward skeptics about the current strategy or its underlying rationale. Among those whose views have been silenced or been shouted down are Arron Ginn and Dr. David Katz. In Ginn's case, our new Silicon Valley truth-squad took down his mid-March essay on Medium challenging the basis of our SARS-CoV-2 response, particularly the immediacy with which both data and tactics from China were accepted as "best practice" in combating covid-19. On March 20, Dr. David Katz was taken to task for a New York Times OpEd in which he suggested the fight against SARS-CoV-2 might be worse than the disease itself, calling for a much more targeted approach.
Beaker: Bunsen Honeydew Skeptic

 Meanwhile, what if the Swedes are onto something? Merely asking the question gets one dragged into a partisan black hole. What if Sweden's relatively light-touch, targeted approach to SARS-CoV-2 looks 6 months from now to have worked just as well as more draconian tactics deployed in Singapore or South Korea? What if, as some of those advising the Swedes predict, 40% of Stockholm may be exposed by the end of May, perhaps conferring a kind of herd immunity?

Meanwhile, the majority of us cower in our basements, look in terror at approaching human beings, and wait for the inevitable second-wave that "experts" worry could be far worse than the first.

Of course there will be a second wave. A lot of us have sacrificed our mental and economic health going out of our way to avoid being exposed to it.

Hero Worship

My last complaint is with respect to the hero-worship that has suddenly been bathed upon our public health officials. I bristle at a lot of of this, first, because this is what they signed on for. If you are the chief medical officer of some jurisdiction, you get the big bucks to do exactly what you are doing. I feel for the "front line" medical staff whose systems were caught unprepared with sufficient equipment and personal protective gear. I my mind, that's a failure of government and the health systems who should have seen this coming; SARS-CoV-2 was not a "black swan" event.

However, I am also mindful that it has been the advice of public health officials that generated these blunt-instrument lockdowns in the first place. It's also our public heath officials who are presenting a narrow statistical picture of what's going on and sounding the alarm about staying home, sanitize, wear masks, and stay away from others.

I get it. In order to get folks to comply, perhaps you need to scare the hell out of them. But public health authorities are trained to focus on public health, not necessarily the broader needs of our society. Infectious disease experts are on the lookout for infectious disease, see it around every corner, and want to take all necessary measures to eradicate it. Surgeons are trained mostly to see things in terms of the need to operate. Dentists see plaque, gum disease, and the need for fillings everywhere. In other words, your training lends itself to bias in what you see.

The dominance of public health authorities over this pandemic has given way to cautious economic re-opening plans. But none of them seem happy about it.

For a lot of people, suggesting the doctors have been in charge for too long puts me in the same camp as some of the most reactionary, anti-science, MAGA-hat-wearing, militia nuts. Relax.
Challenging the purveyors of science doesn't automatically make you some sort of anti-vax lunatic who likes to holiday near Area 51. I am all for expertise. In fact, I lament the erosion of trust we have in expertise, a lot of which has been mindlessly propagated by Donald Trump's attacks on the "deep state" and those experts who work in it. However, challenging science and medicine should be no less routine than challenging what any other profession peddles as expertise. A lot of terrible things have been done to humans in the name of science and medicine. Given the outsized impact the shutdown is having on most people's lives, there is an obligation to challenge what we are being told. I just wish it could be done devoid of politics and fear.

Where is FDR?

Although there's no good time for a pandemic, SARS-CoV-2 arrived at an inopportune moment in global politics. We were a rudderless ship of seething anger, division, and the threat of conflict prior to SARS-CoV-2. The virus has become a political football to kick around domestically and internationally, all while adding considerable fear to the mix.

During his inaugural address in January 1933, President Roosevelt famously said that "the only thing we have to fear is fear itself." I've personally always found those comments a little trite. Yet, even as the Great Depression worsened and the clouds of political nationalism darkened over Europe and Japan, FDR still spent much of the next decade calmly trying to convince Americans brighter days were ahead.

With the possible exception of Queen Elizabeth's April 5 speech about the pandemic, there are few voices of hope and reassurance around. It was only the fifth such address during Elizabeth's reign as Queen and at 94 she's seen a lot. We could all use fewer body-count tickers, predictions of dystopian futures in which we live in our basements and venture out only in strictly controlled isolation, and a lot more of this.
















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