Saturday, March 28, 2020

COVID-19 update March 28 2020

Here is today's update:

1) MAINTAIN SOCIAL DISTANCING !!!  TWO METRES APART MEANS THAT YOU SHOULD BE NO CLOSER TO ANYONE ELSE THAN YOUR OWN HEIGHT PLUS A LITTLE BIT MORE, OR NO CLOSER THAN THE DISTANCE FROM FINGERTIP TO FINGERTIP IF YOU EXTEND BOTH ARMS OUT.

2) WASH YOUR HANDS USING SOAP AND WATER, ESPECIALLY IF YOU HAVE TOUCHED SOMETHING ANYONE ELSE MIGHT HAVE TOUCHED !!! 

MAKE SURE YOU KNOW GOOD HAND-WASHING TECHNIQUE:  SCRUB WITH SOAP, COVER ALL SURFACES OF YOUR HANDS, FINGERNAILS, BETWEEN FINGERS.

I SUGGEST CLEANING THE TAP WITH SOAP AND WATER BEFORE YOU START WASHING YOUR HANDS.   THIS HELPS YOURSELF AND OTHERS.

USE A CLEAN TOWEL AFTERWARDS.  OPEN DOOR WITH DISPOSABLE TOWEL, WHICH WOULD THEN BE THROWN OUT.

3) AVOID GOING OUT UNLESS IT IS FOR A TRULY ESSENTIAL ACTIVITY !!!   IF YOU ARE HAVING BRIEF DAILY EXERCISE OUTSIDE, GO AT A TIME WHEN FEW OTHERS ARE OUT, AND DO NOT GO TO PLACES WHICH ARE CROWDED !!!

Other issues:

- Masks are in short supply by front-line workers who need them desperately.  But there is also pretty good evidence that widespread usage of masks in the entire population could be an effective way to reduce viral spread. The mechanism would both be to prevent exposure to viruses in healthy people, but also to reduce the release of viruses into the environment by people carrying the virus (including those who are not yet having symptoms).

-I would like to see more and better evidence about how to make a useful, effective home-made mask.  I suspect that most any mask is better than none.

-There is some evidence that the severity of illness is higher if one is exposed to higher numbers of viral particles, so any tactic to reduce viral exposure, even if it is not perfect, may reduce disease severity in those who subsequently get infected. 

My previous post about "COVID-Hotels" :  this is an idea to enlist young, healthy volunteers under age 30 to be quarantined and deliberately exposed to COVID infection, in order to gain immunity, and in order to participate in extremely rapid, rigorous, randomized trials of preventative and active treatments, including medications and vaccines.   The risk of this approach would be approximately a 0.1 % death rate, but it would be done voluntarily, and the risk is equivalent to someone volunteering to be a soldier for a 1-2 month tour of duty in a world war, or of volunteering to be a test pilot, etc.  With the new info about lower disease severity with lower viral loads, the risk to these volunteers could be further reduced by using a technique called "variolation."

This idea appears not to have attracted any attention on Twitter (@DrGarthK), which I find unfortunate since I think it could rapidly advance research in these desperate times, where hundreds or thousands are dying from this daily, and where the existing research needs to be greatly accelerated.

All of these ideas are works in progress.  I admit I could be wrong about things, and I invite everyone to critically review, scrutinize, criticize, etc. so that the ideas can be corrected or updated or discarded as needed.  This is what science is all about, and to solve this problem we need to be doing the best science as quickly as possible, on a massive scale.

Friday, March 27, 2020

COVID-19 update

I have updated my idea for a voluntary 8-week quarantine for healthy adults under age 30, in which participants would give informed consent to be inoculated with COVID-19, in order to leave the quarantine immune, and therefore able to work and help others freely, without further anxiety, without risk of getting infected, and without risk of infecting others.

See my earlier post, which I have edited: https://garthkroeker.blogspot.com/2020/03/covid-19-management-brainstorm-ideas.html


Tuesday, March 24, 2020

COVID-19 Management Brainstorm Ideas, Part I: COVID Hotels

The idea I am about to propose is just a hypothesis, NOT a recommendation.  I am not qualified to make recommendations, except for psychiatric issues, but I feel I am qualified to ask questions and put forward new ideas to be tested.

I invite anyone reading this, especially experts in infectious diseases, epidemiology, or public health, to critique these ideas--shoot my ideas down if that's what's needed!   But I'd like to hear what you think.

Here is my first idea, I call it "COVID Hotels."

COVID HOTELS

A COVID hotel would be a building sealed off from the outside world.   Nobody would be allowed in or out without exhaustive screening and quarantine.  It could use a literal hotel building, such as the Marriott or the Holiday Inn.

Every member of the staff of the hotel would need to have previous COVID-19 infection, and would need to have proof of having recovered from COVID-19.  Staff would have to subject themselves before beginning employment, voluntarily and with informed consent, to be exposed to a viral inoculation of COVID-19, then followed for several weeks, to demonstrate that they have full immunity.   The staff would consist of basic workers, including food and cleaning staff, but there would also be doctors, nurses,  researchers, and entertainers.

The hotel would have a research lab.

The hotel would have an intensive care unit, with enough spaces to accommodate the approximate 5% of guests who might need this (this percentage would have to be adjusted based on the best and most recent evidence).

New guests at the hotel would be COVID-19 negative.  They would have to be in perfect health and under 30 years old.  They would of course have to volunteer, with detailed informed consent, to enter the hotel.

Upon entry, guests would be required to stay until they had acquired COVID-19 and fully recovered from it.

The risk to each guest would therefore be approximately a 0.1 % risk of death.  This is the biggest ethical question about my idea.

There could be a variety of opportunities for research.  For example, some guests could be randomized to use face masks, others not, and they could be followed over the next month to see if mask usage would affect infection rates.

Genetic research could be done, to determine if there are genomic variants that confer risk or resistance to developing infection or more severe disease easily.

Other guests could be randomized to try a prophylactic drug (such as chloroquine) vs. placebo, upon entry, to answer definitively if these drugs are actually beneficial to either reduce infection rates or reduce the severity of subsequent disease.

Other guests would be directly inoculated with the virus upon admission.  The inoculation method could also be varied in a randomized controlled manner, for example to test the hypothesis that gradual low-dose viral exposure might reduce the severity of subsequent disease compared to being exposed to a sudden high viral load.

Viral testing would be done daily, with viral load counts etc. if possible.

Every guest would eventually have full exposure and infection with COVID-19, and because of the healthy young demographic, almost everyone would recover uneventfully.  Those who did struggle would be cared for, if necessary, in the hotel ICU.

Every surviving guest would recover, and hopefully become immune to COVID.  Proof of immunity would once again have to be established, by a re-inoculation with a large dose of the virus, then following for weeks to guarantee that there would be no new infection.

Once these guests had recovered, with absolute certain virologic proof of immunity and no virus shedding, they could be released into the community.

Guests who were released could then go on to become staff in a new COVID hotel.

BENEFITS 

The benefits include developing a clearly identified group of people who are immune, who would then be relieved of their own anxiety, be guaranteed of their subsequent health, and who could safely be employed to care for others or begin normal work to boost the economy.

Health care workers and other high-risk staff could also be encouraged to volunteer for this, and in so doing we would develop a much healthier, safer, happier cohort of health care professionals.  Immense anxiety in them could be instantly prevented or relieved, since they would have no worries anymore about getting infected again, or passing infection to their loved ones.

If the idea was employed on a massive scale, it could lead to massive numbers of immune people in the community, and help reduce the rate of spread.

If convalescent plasma proves to be an effective treatment for COVID-19, then the recovered volunteers from this cohort would be a rich, safe source of plasma to treat acutely ill COVID-19 patients.

I suspect that one of the biggest sources of COVID-19 contagion in the world is asymptomatic people who are COVID-19 positive and under age 30.  This technique would start to directly target and eliminate this source of infectivity.

Another benefit is the rich opportunity for extremely clear randomized-controlled studies of infection behaviour, prevention and treatment techniques.

RISKS 

The main risk would be of severe illness and death in a small number of guests.  If the risk is truly 0.1%, this represents a whole year's worth of baseline mortality risk (or so) for someone under 30. 

Another risk is to consider whether it is a cost-effective approach, since it would involve dedicated resources.  My hypothesis is that it would be very cost-effective compared to the status quo.

Another risk could be that it did not work, i.e. that people did not become immune.  That would be a catastrophically depressing thing, if true, but pretty important to know in any case.

COMPARISON TO VOLUNTEERING IN A WORLD WAR

The mortality or morbidity risks of this plan could be compared to the risks of someone joining the military, voluntarily, to serve their country in a major war.  In World War II, about a million Canadians served in the military, of whom over 42 000 died (4 %), and of whom over 55 000 were injured (5 %).  This is a casualty rate 50 times higher than the expected casualty rate of the plan I am describing above.

This is a world war against COVID-19.  Let's build an army to fight it.

In compensation to volunteers for this plan, they could be treated as war heroes, and given full veterans' benefits for themselves and their families afterwards.


Please let me know what you think of this idea.



Monday, March 23, 2020

COVID-19

This is an edited copy of a series of tweets I just published this morning on Twitter (@DrGarthK).


I'm a psychiatrist, and I have no business giving opinions outside my expertise, but I feel I have to say my thoughts in some public way about what I think should be done:

Massive-scale social distancing with extremely strict legal and police enforcement, is absolutely essential to save lives!  


But many people are not taking this seriously enough.  I have seen people gathering and playing at the beach or other public areas, seemingly oblivious to what is going on.  In other cases, I have seen people refusing to give others space on sidewalks; my impression is that some people believe that the more careful among us are over-reacting, and they are not going to indulge us by cooperating with social distancing rules.  

It is human nature, a product of psychological biases and hubris, to underestimate or dismiss personal risks of many behaviours (such as smoking or unsafe sex).  And if risks change, we are more accustomed to continue a familiar, previously safe status quo.  

In this case, right now today, we do not have the time to persuade and educate people about the risks in a casual way, as we would about smoking, sunscreen use, condoms, etc.  


Police and Military 

The required safety behaviours have to be enforced immediately with the full power of the state (including police and the military, as well as overwhelming social pressure), in order to save thousands, or millions, of lives.  Yes, I am advocating martial law!

This requires a temporary suspension of personal freedom, which is scary anywhere in the world, but especially in a free democracy like Canada.  Sadly, this is what we need now. 

Testing on a Massive Scale

We also need testing capacity for the virus increased on a massive scale, so that everyone in the population can be tested, not just once, but every week -- it should be like what one person (@paulromer) on Twitter compared to getting your morning coffee at a drive-through.  

This will require a massive investment, many billions of dollars, in testing technology, with the money supplied using the full power of the state (using emergency or war powers).  This will be far less money than what will be needed otherwise.  

On an encouraging note, I see that news about better, faster testing technology, is coming out every day.  

If we test EVERYONE, we can isolate every single positive person immediately (including the many asymptomatic people) and theoretically end the pandemic in weeks. 

Suppression of False Information

I am shocked and disgusted by seeing various famous people minimizing the magnitude of this crisis, and much as I value free speech (in the style of Jonathan Haidt) I think these opinions should be removed and censured in the media, again using the power of the state, since unfortunately these famous voices have some power to persuade many people, leading to suffering and death for many. 

Massive Increase in Medical Capacity & Research

We are likely to need a massive increase in hospital capacity urgently, so just like in Wuhan we should build new temporary hospitals immediately.  We will need doctors and nurses urgently trained to do intensive care.  Most doctors and nurses do not know how to do intubations or manage patients on a ventilator.  A training program is needed similar to the mass rapid training of fighter pilots in World War II.  

Non-essential or luxury spaces such as hotels need to be appropriated as temporary hospitals or quarantine units, again using emergency powers of the state. 

Massive, unlimited government funding needs to be given to urgent vaccine and medication development, on a scale similar or greater to the Manhattan Project in World War II. 

Identifying People who have Recovered or who are Immune

People who have recovered from the virus, or who could be shown through new serological testing to be immune, should be identified to prioritize them as workers to help others, assuming they can be proven to have immunity.  I am not sure if recovered patients could be able to donate plasma, or contribute to treatment research efforts in other ways, but of course this should be emphasized and given limitless funding.  

STAY HOME 

Meanwhile, I urge all of you to stay home, keep your distance from others, don't touch your face, wash obsessively, as much as is possible.  Learn about correct hand-washing technique, check these on youtube or other online sources.  The virus probably spreads through contact with contaminated surfaces as well, so wash your hands whenever you have touched something that someone else might have touched or coughed on. 

CANCEL MEETINGS

Cancel all non-essential meetings, even if you might disappoint or let other people down.  I've noticed myself how when I have agreed to something (like to visit someone, to have a professional appointment, or to celebrate a birthday), it is really hard to call and cancel.  There is a real pressure to please other people, or to avoid letting them down.  FORGET ABOUT ALL THAT FOR NOW, AND JUST STAY HOME!  If someone is mad at you for not showing up, they will be grateful to you once this is all over.  

By staying home and doing these other safe actions, most of us are more likely to save other people's lives than our own.  Think of others! 

THINK OF THE CELEBRATION WHEN THIS IS OVER

When this is all over--and I think it could be in months to years--let us come together, celebrate and rebuild our freedom, and do our best as a global society to never let such a disaster ever happen again.  

NEVER AGAIN  

This will require a spirit of care and generosity for all of us in society, including people who are poor or marginalized.  This will require a spirit of care and generosity towards other nations.  Even the most selfish of us must see that helping others is the best way to help ourselves.  

Let's make a goal for everyone, not only in our communities or countries, but in the whole world, to have guaranteed basic income and health care.  If you are wealthy, you can surely enjoy your wealth a whole lot more knowing that everyone around you is taken care of. 

GRATITUDE 

Thank you to some of the great contributors on Twitter about COVID, such as @NAChristakis, @MaxCRoser, and so many others.  As you gather news about COVID, start with them.  

There are many heroes among us, including community health workers, emergency response workers, ER physicians & nurses, cleaning and support staff in hospitals, and of course ICU specialists and all supporting staff.  They should be paid more, and their families should be taken care of, just like we take care of (or should take care of) our veterans and their families.  

I wish you all health and peace.  


On a closing note, I encountered a poem by Lynn Ungar which I found moving and beautiful.  It's called Pandemic.  Have a look, her website is lynnungar.com/poems/


Cancel 

Monday, October 7, 2019

Indistractable: Book Review

 Indistractable, by Nir Eyal, is an instruction manual, teaching us how to make healthy choices with our attention and activities, in the midst of the many addictive distractions of the internet age.

It is a good book,  but most of  its content could be acquired through a brief surfing of the net.

Eyal wrote another book in 2014 called Hooked: How to Build Habit-Forming Products. Ironically, this earlier book uses his knowledge of persuasion and behavioural psychology to foster the very addictive distractions that Indistractable tries to rescue us from.  In some ways I guess we could compare that to the management of a casino organizing its own addiction treatment program for customers.

The book itself is well-written, and its format is an example of how to keep a reader engaged: the chapters are short, the language is simple and clear, and the main points are summarized at the end of each chapter, then once again at the end of the book.  There is even material provided to get started on a CBT-style program to become "indistractable."  The "indistractable" language is based, I'm sure, on a marketing idea of encouraging an identity-based slogan as a motivational tool.  If one were to wear a t-shirt with the "indistractable" logo it might help motivationally.

The book itself is a product, and I suspect that it will lead to profits for the author.

Yet, the ideas contained within are useful, and worth knowing about.  Aside from simple behavioural techniques (e.g. decluttering your home screen, scheduling in advance, etc.) there is appropriate attention given to identifying the emotions accompanying distracted behaviour, and to identifying core values (e.g. of being a good parent or a good friend) as a primary motivating force to choose relationships or meaningful work rather than surfing Twitter, playing a distracting video game,  or having a text conversation.

This is another example of how therapists or physicians can learn important lessons from people who have expertise in marketing.  It often requires an inspiring persuasive message to help someone who is struggling with depression, anxiety, addictions, or other problems to make positive, sustained engagements with meaningful life change.