Reflections on Pandemic Management

During the pandemic I wrote a lot, in terms of analysis and encouragement of public health measures.  Some of my contributions were on this Blog, others were on Twitter.  To this day, I think that the measures taken to manage the pandemic were for the most part necessary and successful, for example restricted activity, masking, and vaccine policy.  

The COVID vaccines in particular have been one of the great achievements in the history of medicine.  

But here are some ideas about ways I think it could have been done better: in sharing this I know I run the risk of dabbling into territory that many would consider outside my lane of expertise.  That was a constant frustration for public health experts during the pandemic.  

However, I was conscious all the way through the pandemic that we did not adequately use the most powerful tool available in science and medicine to evaluate the effectiveness and optimize the efficiency of an intervention: the Randomized Controlled Trial.   

And also in dealing with people who were extremely resistant to adopting mandated restrictions or vaccines, there could have been a way to manage this situation that would have helped rapidly gather much better data about COVID itself, protect the population, while also appeasing people who did not want to get vaccinated or follow restrictions.  

Randomized Controlled Studies (or "Randomized Controlled Trials -- RCTs") 

There were many RCTs during the pandemic, but in my opinion there could have been much more done here, in almost every stage, and there could have been massive public investment to get this done, which subsequently could have saved billions of dollars of economic loss, in addition to saving lives.  

For example, it was very clear from basic science knowledge that masking was valuable to reduce viral contagion.  When some people raised the idea of doing more RCTs on masking, it was met with some resistance, as though we were wasting everyone's time in a dangerous way.  Some used a comparison with doing an RCT of using parachutes when jumping out of an airplane -- obviously this would be recklessly inappropriate, and the entire placebo group would die!  Masks, like parachutes, are obviously effective, and mask proponents made a reasonable case that randomizing people such that a placebo group would not get masks would be needlessly dangerous.  But an RCT does not require that there be a "placebo" wing!  It only requires that the study be randomized to compare one treatment with another.  To follow the parachute analogy, it could be to randomize people jumping out of an airplane to receive one of two different types of parachutes, each of which an accepted standard; or for them to use two different timings for releasing parachutes, if each of these was also within an accepted standard.   

In the case of masks, there could have been RCTs of using different types of masks (e.g. procedure vs. N95), different timings of masking (indoor only vs continuous outside the home), or different replacement times for masks (e.g. re-using N95 masks for days vs replacing them every use), or different N95 use details (e.g. receiving formal instruction on technique vs. not).  And early in the pandemic there was an N95 shortage.  One of the ways to deal with this could have been to randomly distribute the timing of the N95 supply, so that some entire communities would receive an adequate supply first.  Then the entire community would use N95s while adjacent communities would temporarily make do with other types of masks.  Then the disease prevalence rates and hospital admission rates could have been compared between adjacent communities.  This type of design could have been tremendously valuable, since mask use has not only an individual benefit for infection control, but has a collective impact, akin mathematically to the effect of vaccines -- if everyone in the population has a modestly reduced probability of infection, then it could translate to a massive reduction in community prevalence.  If such a study had shown reduced infection and hospitalization rates in the better masked areas, it could have propelled a much more urgent and timely effort to manufacture better masks for everyone, and in the medium term the whole community could have had better access to N95s, saving thousands of lives.   But since such studies were lacking, there was enough doubt about mask effectiveness or effect size to delay the massive investment needed to increase mask production.  

When RCTs are done, it does not settle questions once and for all: in good science, we are always repeating, tweaking, and refining.  New RCTs would have to be done after the first ones, with different details being looked at, or simply for replication.  

One type of mask use behaviour which should have been better guided by evidence, is the use of masks outdoors.  I still see many people outside with their masks, or people wearing them in their cars on the way to work.  It was pretty clear from the ventilation evidence that outdoor mask use was very likely unnecessary, unless one were in very close proximity to crowds, or doing a lot of talking up close.  Perhaps masks would still be needed in playgrounds etc. but certainly not for walks at the beach alone or with just a few people close to you.  

Similarly, RCTs could have been done on ventilation control in buildings.  The basic science on ventilation was one of the most important and underappreciated areas of science during the pandemic.  There was a wonderful group of engineers who had done great work in this area.  Ventilation improvement was also a totally non-controversial intervention:  regardless of one's views about masks or vaccines or restrictions etc., I think everybody would welcome the idea of having better fresh air inside our homes and workplaces.  Ventilation improvements involved air filtration (such as with HEPA or MERV-13 HVAC filters) but also increased fresh air replacement rates.   But the engineers again used the parachute analogy when there were challenges to do RCTs, arguing that their work was established basic science, which didn't need to be tested in an RCT.  But once again, if RCTs had been done, of whole communities which made ventilation improvements, vs communities which did not, we could have much more quickly found a "signal" of improved infection control, and then made much more rapid investments in ventilation improvement technology for everyone.  

In all of these studies, the data to gather should always have been not only rates of infection, but also most importantly rates of severe disease.  Some interventions such as masks arguably could cause a reduction in infection rate, but perhaps in cases of people getting infected despite mask use, they would have inhaled a smaller inoculum, and possibly could subsequently have developed milder disease, since the immune system would have had a little bit more time to respond to the virus before getting overwhelmed.  The question of whether inoculum size impacts disease severity is yet another one which I don't think is well-enough answered by the research.  

The Covid Hotel 

The "COVID hotel" idea was something I proposed early on as a thought experiment at the very least, and there was at least one other scientist in the US who shared this idea as well... but it was received very coldly by experts--when I gently suggested it I got the sense that they thought it was scandalously inappropriate or unethical.  But this idea could have saved thousands of lives, and could have helped gather optimized, crystal-clear data about COVID in terms of the mechanism of transmission, the effectiveness of masks, the impact of ventilation, etc.  This information could have been obtained within a few months, and then could have helped focus optimal interventions with much better clarity and urgency, and to mobilize public investments in such things as masks etc. much sooner.   

Here's the idea: if people refused to be vaccinated, or insisted on having unrestricted freedoms, instead of punishing them using the justice system, they could instead opt to check into a "covid hotel" in which they would choose, with informed consent about risks, to be deliberately infected with COVID under controlled conditions, with optimal medical support available.  Then they would stay in the hotel for a few weeks under quarantine until they were no longer infectious.  Upon checking out, they would have a much lower risk of spreading COVID--the risk would be comparable to a person who had been vaccinated.  In this environment, there could be meticulously controlled experiments to determine if COVID could be transmitted through an airborne route (perhaps all the time, perhaps only in some cases of "superspreaders" etc.), or through a surface contamination route (after all this time, it is not crystal clear that surface contamination was ever a major route of spread).  And there could have been masking studies in this environment to determine if masks (including styles of mask usage and mask type such as N95 vs procedure masks, as well as the proportion of people wearing masks,  etc.) reduced the likelihood of contagion, or reduced the ensuing severity of disease (since the masks even if they didn't prevent infection might at least reduce the inoculum size).  Similarly there could have been meticulous ventilation control studies, to see if improved ventilation reduced contagion.  

In this environment, participants could even be offered to choose modalities of treatment of their choice, delivered by their practitioner of choice. They could try the "alternative treatments" in vogue if they wished, or opt for standard medical care.  This way, there could have been much more rapid evidence to establish the impact of these alternative treatments (all of these alternative remedies have been utterly disproven, but this could have happened much more quickly and persuasively in the "COVID hotel" environment).  

Some of the benefits of this idea would have been much, much better quality data about mask effectiveness, mode of contagion, effectiveness of ventilation improvement, etc.  And there would have been much less spreading of COVID to vulnerable people by people who refused to adhere to public health guidelines.  And there would have been much less upset from people who wanted more freedoms.  In fact these people, instead of being vilified, could have felt like true heroes, even from a scientific point of view.  The cost of this, of course, would have been that people who chose the "COVID hotel" route would have been much more likely to die, or to have severe long-term consequences of COVID.  But this would have been their choice, and if they didn't check into the COVID hotel, they would have subjected themselves to the same risk in the community, with less medical support and therefore an even higher likelihood of medical harm, and all the while they would have spread COVID to many more people, without contributing anything useful to the world's knowledge about the disease.   There are many other examples in life of people who are willing do risky activities, following informed consent: for example, joining the military, the fire department, or doing risky sports such as hang gliding.  

Animal Studies

There were animal studies during COVID.  It's a sensitive topic, since it is important to respect the rights of animals.  But COVID affected the animal world as well, and the research about contagion would have led to benefit for not only human populations but animals as well.  One very particular type of animal study that was never done well enough was to use an animal model to demonstrate spreading modality.  For example, the ventilation outflow from hospital rooms with human COVID patients could have been pumped into an animal enclosure of susceptible animals.  If these animals developed COVID it would have been tremendously strong evidence for airborne transmission in humans.  If, in a follow-up experiment, the same ventilation pipe passed through a HEPA filter first, and then into the animal enclosure, and if these animals did not contract COVID, it would have been incredibly powerful evidence that a simple filtration technique could prevent contagion.   If animals were simply allowed to visit hospital rooms where COVID patients had spent a few days, but who had left, and where the air in these rooms had been replaced using ventilation, then it could have helped determine if surface contamination unequivocally could cause COVID spreading.  It is quite possible that surface spreading was never a major problem, while airborne spreading was a huge problem, hence efforts would have been directed towards ventilation rather than as much surface cleaning.  But we would have needed the research to prove this.  

Vaccine / Restriction Timing

Restrictions were deployed in the pandemic quite wisely, particularly with a view to prevent the nightmare of ICU and hospitalization overflow.  For some individuals, going beyond mandates, they voluntarily maintained restrictions for months or years following vaccination.  One interesting study issue could have been to randomize people to maintain strict restrictions after vaccination for a long period of time, vs. ending restrictions for those people starting about 4 weeks after each vaccination.  This would have caused the unrestricted individuals to have greater exposure to ambient circulating COVID strains, but this would have occurred in the context of good immunity.  As the vaccine strains kept changing, the vaccinated people would continue having new exposures with new strains, and especially as 3-6 months passed after their vaccines, they most likely would have had some mostly mild cases of COVID along the way.  But I wonder if this process would have in the long term led to improved, robust immunity to multiple strains, with the same or lower long-term health risk, while also improving community freedoms, compared to the situation of maintaining continuous long-term restricted behaviour.  In a sense, this idea would suggest that the vaccine and annual boosters would be the primary preventative defense, but then exposures to the ambient COVID strains in the community would subsequently act as "boosters" for previously vaccinated people, and in the long term (measured over 3-5 years or more) lead to equivalent or better health outcomes, with fewer restrictions needed.  Conversely, the studies might instead show that maintaining more restrictions over the longer term would have led to better long-term outcomes.  We can't know for sure, since the studies were never done.

Unfortunately, in the aftermath of the pandemic, there has been increased polarization in the world about public health measures of all types.  We are seeing decreased rates of vaccination against other diseases, and we are seeing a return of various diseases which had previously been nearly eradicated, such as measles.  Just as with Covid, most people who get these diseases will recover ok, but there will be needless cases of severe disease and death, including among young children.  I hope that the field of public health can work hard on the sociopolitical aspects of their profession as well as the epidemiological parts.  But I also wish that some of the best scientific tools, such as RCTs, could be done much more quickly and on a much larger scale than what we saw during the worst years of COVID.  

The Harms of Social Media

 Social media is a miraculous invention:  a way to stay in touch with friends and family, to share thoughts and pictures and videos and common interests, at any moment with perfect convenience, literally with the push of a button (actually, even the force of pushing a button is not actually required, it's just touching a piece of glass!).  

It is an electronic extension of ancient modes of human communication: instead of sharing stories and starting conversations around a campfire with a group of fellow hunter-gatherers or villagers, we have an electronic campfire, which allows 24/7 contact with almost everyone in the whole world.  

Human interaction and communication is a need, and our brains are designed to be very sensitive to social stimuli.  

There are many benefits of using social media, but it is in my opinion very harmful, both on an individual level and as a national or worldwide community.  

Social media companies of course want you to spend more time on their apps.  The algorithms are designed to feed you information that would interest you more, and keep you looking for longer.  But this isn't necessarily good or healthy!  It's the same mechanism that feeds addiction or any unhealthy habit.  It's like candy for the brain.  The algorithms are not designed to give balanced information, or to help people avoid getting sucked into rabbit holes of misinformation, or to stay healthy, or to foster harmony in communities, they are simply designed to optimize time spent on the apps.  

So people are spending huge amounts of time surfing on social media or other scrolling information sites.  "Doomscrolling" is a very common activity.  For children, there are clear psychological harms--Jonathan Haidt's latest book "The Anxious Generation" is a good place to start reviewing the data on this.  Especially for children, the social comparison that is fed by social media is almost guaranteed to at once absorb attention, but also make people feel bad about themselves.  This could result in an increased rate in mental illnesses such as depression and anxiety disorders.  

And there are secondary costs, as Haidt has also shown:  every hour spent on an app means one less hour doing some other healthy or meaningful human activity, such as playing outside, going for a walk, doing a hobby, studying, conversing with friends in person, or reading a book.  App use fosters both psychological harm and damage to physical health as well, by reducing the amount of exercise we're getting, sometimes interfering with sleep (people are often up late at night looking at their phones; aside from the psychological component driving this, the bright light from the screens further interferes with normal sleep).   

I spent a few years using Twitter.  I am thankful that I stopped using it by the time it had changed names a few years ago.  There were many positives of Twitter for me, professionally:  it was a way to stay informed about the ideas and research of numerous experts in various fields of interest, and to hear their ideas instantaneously, rather than waiting for journal articles to come out (sometimes years later).  At times one could interact directly with the experts.  And one could add on other peripheral or hobby interests, and just feel better informed every day.  During the pandemic I felt Twitter was a good way both to follow news of critical matters daily, but also to contribute a public message as a professional.  

But I ended up spending more and more time on Twitter.  Even during a hike outside, I would find myself pulling out my phone and checking.  Hours were spent on the app that could have been spent reading a book or a journal or a newspaper, or doing some fun activity.  And as I discovered over time, many of the interactions on Twitter were frustrating -- often you couldn't really have a conversation with people.  It was rare for an expert to actually interact with you.   The app created an illusion of connectivity, while very little was actually there.  The one advantage it did have was convenience, and efficiency in terms of cultivating a community of like-minded peers.  Such a community can sometimes be useful, but at worst this feeds the worst tendencies in society, of polarization and division.  

From a psychiatric point of view, I believe it is important to assess internet and social media use.  It should be an essential component of any psychiatric history.  

Consideration should always be given to weaning from social media, to try a few months entirely without it.  You may experience "withdrawal" from it, but after this passes you may feel more free.  If you fear that you'll become less informed, remind yourself that you can just read magazines or newspapers once a week, or once a month, and most likely remain as informed, or even more, compared to doomscrolling.  

On a societal level, I understand that one of the principles at play here is freedom of speech.  If governments were to regulate social media companies this would be seen as interfering with freedoms.  But if we consider that social media and many other internet sites are analogous to addictive products, such as cigarettes or alcohol, maybe we could increase the amount of regulation about how these products are marketed or accessed, especially to children.  

One of Haidt's ideas is to insist that children in school should not be allowed to have their phones during school hours.  I think this is very good idea.  Of course, modern education often makes use of electronic media, but this could be provided in schools using other devices that would not allow kids to be surfing social media during their classroom hours.  

This idea could be extended into adult life, to invite people to set their phones aside much more often.  

Grocery Shopping & Mental Health

 Good nutrition is essential for physical and mental health.  

But changing one's diet is probably not going to cure depression or make your anxiety go away.  In fact, I'm concerned about various trends in health care which exaggerate the effect of dietary change.  For example, there are programs run by professionals with titles such as "food as medicine" in which patients are taught about healthy dietary practices.  But the therapeutic value here is very modest, especially if compared to a well-controlled placebo condition.  It may be beneficial to have nutritional education, dietary change, and regular supportive meetings supervised by a professional, but there would be a lot of nonspecific factors involved here, including a benevolent structure, group support, empathy, and focus on general healthy lifestyle habits other than nutrition, which contribute to clinical improvements.  And sometimes these programs end up recommending various supplements or "alternative" nutritional habits which have a very questionable evidence base.  

The basics of healthy nutrition, however, are simple.  There is a lot of room for individual differences in preferences or restrictions, but the foundation of a healthy diet is vegetables (especially fresh green vegetables); fruit; nuts; whole grains and other complex carbs with high fiber; beans, lentils, and other legumes; lean protein; healthy fats such as olive oil; fish; and much less red meat than the average North American consumes.   High-sugar and simple-carb foods such as pastries, cookies, cakes, candy, etc. should be greatly reduced--often if you've reduced these a lot, you can enjoy the occasional sweet treat even more, without needing to have as much.  One should cut back on the amount of salt.  Ultraprocessed foods, such as chips, processed breakfast cereals,  instant noodles, soft drinks, and fast foods, should be avoided.  

These basics do not lead to some kind of unpleasant, spartan lifestyle, these are the foundations for a wonderful, sensually pleasing diet in which every meal can be a joy of life, with no end of variety possible, from simple snacks to daily meals to gourmet adventures.  The enjoyment of this type of diet involves not only the nutritional benefits, but also the process of shopping (for example at farmers' markets, produce shops, or berry picking) and meal preparation (in the kitchen).  These activities touch upon basic joys and skills of life that have been part of human ancestral history for thousands of years.    

When wandering through a major grocery store the other day, I was struck by how hard it can be to make healthy choices.  These stores have incredible variety.  It's easy to find all the perfect, healthy foods listed above.  But the problem is that junk food, ultraprocessed foods, candy, etc. are all marketed aggressively.  Whole rows of the grocery store are dedicated to junk food.  Shelf after shelf of chips, cookies, soft drinks, or even "fake health foods" such as sugary cereals or "vitamin water."  At the cashier, there is yet another opportunity to buy chocolate bars and other candy.  Even in the areas with healthier foods, such as the produce section or the aisles with baking products, there is often a display of some kind of ultraprocessed food or junk food on special.  Even health-oriented grocery stores such as Whole Foods feature similar marketing.   It's the same even at pharmacies which sell food products.  And even in a hospital, whether it be at the cafeteria or at vending machines, there is an endless supply of junk food.  Lunches served at schools, or food provided after sports events, often consist of pizza, burgers, and cake.  When my own children were going to elementary school, I noted the common practice of parents sending their kids to school every day with a lunch box containing a chocolate bar, a bag of chips, and either a juice box (filled with sugary fruit juice), chocolate milk, or even a Coke.  

Junk food is designed to be enjoyable to eat, so that people will buy more of it.  In this way it is comparable to addictive products such as cigarettes.  Unlike cigarettes, there are no restrictions about how they are marketed.  And the companies manufacturing these products, and the grocery stores selling them, are earning billions.   So we have a whole generation of people, including young children, who are basically addicted to junk food.  The health consequences of this include much higher rates of obesity, as well as a likely lifelong, chronic decline in physical and mental health.  Another consequence is a decline in culinary culture--many people just aren't interested in the artistry of food, if they are addicted to processed products.  

One of my interests this past year has been learning Chinese, and as part of this I like to watch Mandarin language movies and TV series -- the Chinese culinary culture has probably been the healthiest one in the world, and likely is a factor contributing to better health and longevity in this population.  But even in China it appears that ultraprocessed foods are disturbingly common.  In modern Chinese movies, we often see the characters eating pizza (it seems a common North American chain restaurant is popular there) or visiting a grocery store, the shelves stocked floor to ceiling with bags of chips and instant noodles etc.  So even in the healthiest culinary culture in the world, the bad nutritional habits of the West have crept in.  

What can be done about this?  Aside from individual education on this matter, and striving to make healthier choices, I think that public measures can help.  Other countries in the world are experimenting with having taxes on sugary foods, ultraprocessed foods, etc., and restricting marketing, especially to children.  It's a similar approach as we used to help reduce cigarette smoking in the population--it didn't require banning anything (and taking away anyone's freedom), it just required restrictions on advertising, display, marketing, and introducing a tax on the product.  Another public measure that I would love to see is a subsidy on healthy foods such as vegetables, so that everyone could afford them more easily.  This would have benefits not only for individual health and nutrition, it would also be beneficial for the environment, for farmers, and would be economically more efficient.  

Navigating Chaotic Times

This is a sequel to previous posts dealing with some of the changes we are seeing in world events in the past months.  

The chaos we are seeing is totally expected, given the deep behavioural, cognitive, and personality issues of the leader causing these new problems.  

I am disappointed that news media does not seem to adequately grasp the enormity of this problem.  It is important for journalists to report on the terrible policies and consequences of these policies, but the overarching problem is something worse than any collection of policy events:  once again, we are in a position analogous to having a mean-spirited, capricious, unintelligent, unskilled, humorless, and vindictive middle-school bully take over the piloting of a jumbo jet.  This time, the bully is in a mood to play with the controls of the aircraft, and he may find the fearful response of the passengers to be entertaining.  Many of the safety features of the plane have now been removed.  I really think there is almost no limit to how much harm can be done as this situation continues.  

Of course, this situation is doing great harm to mental health, in a variety of ways.  For starters, there will be economic hardship and a lack of security that will dampen morale. 

One of the most common causes of psychological stress at this point is compulsive or excessive consumption of news, often coming from news streaming sites or social media.  Some of us are spending many hours a day “doomscrolling” — this is tiring and depressing, and does nothing helpful.  This is a contagious phenomenon, since even if you stop “doomscrolling” it may be that your friends or family have not stopped, so every conversation gets tainted by a cloud of doom from the daily news events.  

So I recommend, as a mental health intervention, that we all severely restrict “doomscrolling” behaviour, or other similar phenomena such as having a news channel playing in the background of your home at all times.   While it is important to be informed, I think that it is adequate to follow news once every 1-4 weeks, preferably by reading a few different physical newspapers or news magazines, rather than by obtaining news from social media or from your phone.  The “doomscrolling” is a behavioural addiction.  And furthermore, this form of news propagation is one of the reasons this situation has developed in the first place, since electronic media make it easier for people to form “echo chambers” of like-minded people, often leading to worse and worse polarization and extremism.  Unfortunately the economics of news propagation is such that echo chambers and behavioural addiction, with all the malignant polarization that follows, is profitable for the news companies.  

What else can be done?  I think this is a difficult question.  But one insight from history is this:  if we receive only a negative or catastrophic piece of information, especially one example after the next, then we are likely to be demoralized, tired, perhaps infuriated, perhaps resigned.  But if whenever we take in negative news, we also receive a message about what can be done about it to help, then the process can be quite different — it can be energizing, and motivate people to take positive action.  So I encourage you, whenever you are watching the news, to always ask yourself what you can do to help.  If you can’t think of what to do, consider what Mr. Rogers said, “look for the helpers.”   Actions could involve letters to political leaders; peaceful protest;  and changing consumer behaviour so as not to reward companies or individuals associated with the negative world events, and to communicate to companies to encourage them to take positive leadership steps to stand up to the problems going on.   Of course it is absolutely crucial that we all vote, and do our best to encourage others to be well-educated about the issues, and then to vote themselves.  

Another piece of strong advice — and this follows many of my other posts in the past years, including those about the pandemic: we humans are intensely tribal by nature.  It is an evolved trait that causes humans to form strong communities; these communities can then thrive, economically and culturally.  As I’ve discussed in other posts, and as many great psychologists have discussed (such as Jonathan Haidt and others), our tribal nature causes us to form “ingroups” containing people who share similar beliefs, histories, political leanings, language, culture, religion, and appearance.  These ingroups are extensions of our biological families, and historically were in fact more likely to consist of extended relatives in a village environment.  Loyalty to these ingroups is like loyalty to family.  This is a normal and often beautiful thing, but the dark side of it is that ingroups become impervious to influence by outgroup members, even when the ingroups are engaging in destructive or bizarre behaviours, and becoming more and more extreme or even cult-like.  But all of us are tribal, and our natural reaction to dealing with another “tribe” is to defend ourselves, and to attack the other.  But this is just a recipe for a spiral of escalating conflict.  

In this case, we cannot just stick to our ingroups in dealing with this problem.  While it is important to energize our voices, to rally our own “ingroup,” and to gather and motivate peers and fellow citizens who are similarly concerned by the events going on, we must also reach out to those on the other side of the political and ideological divide.  There should be gentle efforts to understand why people on the other side of the ideological divide (that is, those who enthusiastically chose the bully to fly the jumbo jet) continue to believe or act as they do.  The interactions should take place with dignity and respect.  If such respect is provided, those on the “other side” are more likely to listen to other arguments, or to hear evidence about the bad things that are happening.  Without such respect, ideological opponents may simply double down with their previous beliefs, and may either not look at any evidence of the bad things going on, or may think that the evidence is “fake news.”   If you use social media regularly (such as Facebook or X) be careful that you are not simply interacting with others who share the exact same view, and that you are not simply attacking or mocking those who have a different view — instead, always be mindful about whether your contributions and involvement in social media could have a positive impact to engage those people who are on the other side of an ideological divide.  In any case, we all need to be taking positive action, rising to this difficult occasion with gentle, dignified strength and respect, while resisting the temptation to let our anger dominate our actions in harmful ways.   

I am hoping to see more leadership in this regard, and even heroism, from other parts of society.  Unfortunately the situation may be sufficiently dire at this point that individuals or companies who desire to do the right thing, by standing up to what is going on, may face some risks of economic or other repercussions.  But such is the nature of being a hero, to be brave in the name of doing the right thing and helping others.  As I’ve said before, I wish that the psychiatric community could come together to make public statements about the dangers of psychopathy and malignant narcissism in a group leader (in this case, the group being an entire nation).  I wish that there could be leadership from small and large corporations to stand up to support the best of their nation’s values in light of what is going on.  I wish that companies involved in news media could do much more work to address the problems of extreme tribalism, propagation of false information, and addictive news consumption.  I wish that religious leaders could come forward to speak compassionately to their followers, to support the best values their religions offer, including grace, wisdom, compassion, altruism, kindness to strangers, and humility: these are the values that will guide us together safely through these difficult times.