Mental Health Reform: reflections & ideas for change

On February 1, 2020 I began work as a psychiatrist at my own private office.  

Before then I worked at a large academic institution for about 20 years, and was the leader of the psychiatric team there for 13 years. I have always loved my work very much.  I have been very privileged and lucky to have had such a job, during those 20 years.  It has been meaningful and enjoyable, for the most part, to care for my patients over the years.  And there were many wonderful colleagues and other staff at my clinic, who made our work more enjoyable, safe, and helpful.  We worked very, very hard.  There was a sense of community, like a type of family.  But I feel incredible relief to have left this position.  Now, after 15 months away from it, I feel I can have a gentle reflection upon some of the problems which developed there over the years. 

I would like to describe some instances of what I think can go wrong during a well-meaning effort to plan for change in community mental health care.  I do not want this post to be understood as a ranting complaint from a disgruntled person, but rather I would hope to simply tell the truth, from my point of view, about some events that happened, with reflections on ways to prevent such problems in the future.   I am happy and grateful for my present and my past, but I do feel there are a few things to be said.  

Mental health reform became a big issue in the community where I worked, over the last 5 years or more.  A lot of extra money appeared in the budget for this, and some care was wisely taken to plan for how to spend it. 

Many meetings took place, to discuss mental health care reform.  

A team of consultants from another country was hired, and flown over several times to assess the situation. I presume this occurred at quite considerable expense.   Their recommendations and presentations appeared to be a very polished lobbying effort.  During these presentations, which included some academic citations to support their positions, there was never actually any room for debate about the research they were citing or for the positions they were advocating, despite the presence in our academic community of many experts.  

A plan eventually developed, devoted to the idea of collaboration among different helping disciplines.  

The meetings would tend to begin with a lot of self-congratulation about progress, followed by lengthy, repetitive monologues, laden with jargon.  I was usually the only psychiatrist present in all of these meetings.  I was always very concerned that I never come across as arrogant or disrespectful of others, given my own privileged position.   I abhor professional arrogance,  so I aimed to remain quiet, to be calm, to try to listen respectfully. 

But eventually, after many hours of such meetings, I realized that major decisions were being made about health care planning, with a lot of money involved, with almost no debate or critical challenge.  These changes affected my patients, my colleagues, my morale, the group's morale, and my own philosophy of practice.    Almost none of the money was directly helping my clinic.  I personally did not have any voice in these meetings: my comments or input were not welcomed, and I think I actually was considered difficult or uncooperative because I didn't seem to go along with the plan.   On several occasions I was told, very directly, to discontinue my comments.   When I gathered feedback from professional colleagues (who otherwise had no voice in all of this), and summarized their comments in a brief written document (as was requested of me),  the document was rejected, and never submitted, because it was deemed not positive enough.  

The foundations of my own philosophy of practice are simple:  make time for patients, listen to them, be available, be gentle, be kind, build trust, be humble, try to honour a patient's wishes.  I believe that good care cannot be rushed.  Mental health care can sometimes be done with great efficiency and speed, but more often it takes a lot of time and patience.  Almost everyone I have ever seen in my career has been tired of seeing people for help who did not really have time for them.  

In terms of larger-scale, organizational philosophy, my foundation would also be simple: take care of the staff!  Everyone, including cleaning staff, clerical workers, nurses, GPs, and specialists, should feel safe, respected, cared for, and heard, in a healthy organization.  Be on the lookout for "burnout" especially when a system is strained by high demand.  Policies that seem efficient on the surface may be quite deeply harmful, if they lead to a type of "assembly line" experience for either the staff or for the people trying to access the system.    

Some tools of efficiency, such as computerized records systems, may seem efficient, and may have many uses, but they may be expensive, inconvenient, slow, prone to error, time-consuming, obstructive to rapport with patients, and very heavily marketed by software companies which are earning a lot of money, often trying to sell impressive-sounding features which are actually unnecessary (I feel very fortunate to have found a perfect electronic records system myself, called "Jane," which is far superior, and much less expensive, than the system used at my previous workplace).   

 One reason I wanted to speak out, even at risk of sounding "difficult" or uncooperative, was to advocate for my patients. I was responsible for the care of patients with the most severe, chronic mental illnesses, yet my input about mental health was not allowed, or was met with rolled eyes and even direct requests that I stay quiet.  Furthermore, none of my psychiatric colleagues were ever present or allowed to contribute to these meetings, beyond a couple of occasions in several years. These colleagues were never officially on the payroll, they always worked privately and paid overhead to be in our group. In fact, my psychiatrist colleagues were always a free service from the point of view of the institutional budget--they actually earned money for the institution by paying overhead.  They earned less money than most other psychiatrists in the community, but stuck with the group due to their love of the work.  These colleagues never had any voice in the institution's mental health care policy.  I felt that I had to speak for this group as well. 

This went on for years. Patient care suffered.  I was the only person in all of these meetings able to do psychiatric consultations for people with severe illness who had been waiting for months, yet I was sitting in redundant, lengthy policy meetings in which I was not even allowed to contribute.  I thought of my patients, which led me to try to speak up, even at risk of sounding "difficult."  

One of the themes of the new policy was "collaboration."  But ironically, because of the policy meetings, the actual collaboration meetings which I and my counselor colleagues had enjoyed for years, in which we would discuss mental health care in general, as well as immediate, serious clinical issues about specific students, were cancelled.

One summer, there was a series of meetings devoted to drafting a formal care algorithm for treating depression.  This was yet another absurd journey.  The subject was the foundation of what most of the counselors in the group had studied for years, in graduate school.  The subject was arguably the focus of my entire 20-year career.  Yet, once again, I and other experienced professional colleagues were mostly silenced, and assigned into small groups to prepare some kind of treatment "algorithm" in an essay-like form. I thought of all the patients who were not seen while we were doing this.  

This was especially troubling, as I found the whole process more and more ethically objectionable.  We should begin by ensuring that people are assessed well, are respected, are heard, and their wishes about their own care honoured to the best of our ability.  Many algorithmic branches should be negotiated by a well-educated caregiver and the patient or client, not dictated by a flow chart.  Good care requires deep attention to building a trusting, caring relationship, empathy, understanding, and a therapeutic alliance.  Furthermore, restricting any "algorithm" to only consider depression is inappropriate, since most people coming for help have various other problems other than depression, which would all have to be considered together. 

During another meeting the entire group of 100 or so people was asked in advance to fill out a Myers-Briggs questionnaire.   The entire group was subdivided according to their Myers-Briggs personality type, and made to sit at separate tables.  Some Myers-Briggs types are more rare, while others are more common.  Many tables were full.  A few tables had only one person.   

The Myers-Briggs personality assessment has very limited validity.  It can lead to fallacious polarization of traits which actually lie on a continuum.   But in any case, personal testing data about psychological traits or symptoms is intimate:  it is arguably in a similar league as any other medical test.    It is inappropriate to have to share such information in a group setting.  There were a few people in the less common personality categories who ended up sitting alone.   To divide the group up like this was an example of what NOT to do with mental health labeling: to actually separate people on the basis of differences, leaving some people alone.  It was introducing new labels, stigma, and separation, needlessly.  To top things off, it surely would have cost money, going to a company making large profits,  to purchase these tests.  In addition to the cost of paying everyone's salary for this, there was also the cost of room reservation and catering.  Most importantly, there was once again the cost of severely ill patients who were not being seen.  

Another meeting featured a visiting expert, who had some national fame.   I would once again love to know how much his travel expenses and speaking fees were.    He was a charismatic speaker, with remarkable orational skills.  Everyone loved his presentation.  But one thing stood out for me...one of his opinions had to do with what he thought were excessive mental health resources being offered to people with what he considered minor problems.  In a hushed tone, he summarized the problem as being "narcissistic entitlement" on the part of the people seeking mental health care.  I have no doubt that there is a lot of narcissistic entitlement out there, but to dismiss an entire category of people, and to advocate for major policy change in mental health, based on this assumption, is prejudicial.  I have to wonder how often some famous policy-makers actually work with patients in a therapy setting.   Once again, there was no actual debate on this, just discussion groups affirming what had already been said.  

Another meeting was entitled "Stepped Care Anxiety."  It was a presentation led by a local research psychiatrist with a lot of experience in community programs, though someone who spent little time actually seeing or caring for patients at this point in his career.  Once again, clinical care of patients was cancelled in order for staff to attend this presentation.  Initially I thought the meeting would literally be about "stepped care anxiety"-- that is, anxiety induced in caregivers upon being presented with another tiresome trendy catchphrase.   But the title was actually just a product of some difficulties with English, and the meeting was about "stepped care FOR anxiety."  Basically, the idea of stepped care is to offer more care to people who have more severe problems, and less care to people with less severe problems.  As people improve, start to reduce their level of care.  This is a statement of the obvious, of course, and is what all of us would naturally do anyway.  There seemed to be an implicit assumption that psychiatrists in particular would be seeing patients unnecessarily, even if they were well or not in need of further care, and that we needed guidance to step away from this wasteful practice.   I was asked to be well-prepared for this meeting, by reviewing the materials in advance.  But once again there was no real meaningful discussion about this, aside from a review of obvious principles.  A deeper discussion of care would have allowed for the idea of actually spending time to know patients over a longer period of time, regardless of symptom severity, so as to prevent severe recurrences of mental illness, rather than saving our clinical attention only for emergencies.   Stepped care, when applied dogmatically, is yet another ideological system which leads to superficiality of care, a type of fast-food equivalent in mental health provision.  

After a lull in these meetings, the next chapter began with new hiring in the institution.  This time even more money was spent on expensive administrative positions, instead of on badly-needed direct health care.    Some of the administrative positions were filled by clinicians, so in addition to the cost of paying these administrative salaries, an extra cost to the community was of an expert clinician paid to do office work and attend meetings instead of using desperately needed skills to help patients directly.  I think of how many hundreds of thousands of dollars per year were spent on this increase in administrative funding, while actual clinical care languished.  Our clinical unit had barely grown in decades, despite serving a community which had rapidly expanded, perhaps even doubled in size.  Encounters with the administration were negative and morale-depleting.  I dreaded them.  I really just wanted to see and take care of my patients.  My other priority was to take care of my coworkers and colleagues.  But I felt powerless to do anything for them.    

One of the meetings--again arranged by cancelling our actual work with patients--was with a visiting specialist who had invented a new way to see more patients more quickly.  A psychiatrist would join a GP for a 30-minute "mini-assessment."  That way, more people could have psychiatry assessments, there would be shorter wait lists, and the primary care doctors would feel more supported.  Once again, there was no opportunity for any critical discussion, during or after this presentation.    The thing is, such assessments are pretty much the opposite of what I consider to be good psychiatric practice.  Assessments cannot be rushed.   Imagine if you had to see someone for a difficult, very personal problem or issue, and had to discuss it in 30 minutes, with two people in the room, one of whom a stranger, with the understanding that your future care would be guided by the new expert's opinion during this fragmentary discussion.    It is arrogant on the part of psychiatrists to assume that extremely brief visits could lead to diagnostic or therapeutic insights that the other caregivers had not already thought of.    Such brief assessments, and other schemes in mental health care similar to them, tend to bias the conclusions towards medication management, since this is the easiest type of thing to construe in a short assessment, without knowing a patient well.    Assessments and good care take time--there is no avoiding this!  Relationships cannot be rushed.  

Satisfaction surveys following such changes could also be quite biased and misleading, in the same way that taking a survey of people leaving a fast-food restaurant could give a biased view of food services quality in a community.  Many people might be quite pleased to have convenient fast food, but those who would suffer the most from such policy would not be included in the survey, since they would not be using the services.   

I am deeply relieved to have left that place!  But I miss my colleagues, I know they are good people and skilled professionals.   My decades of work there, despite the frustrations at the end, were a labour of love, for which I am deeply grateful.  While I have voiced some complaints above, the years at my previous position helped make me a better person, and taught me a lot about how to be a good doctor. 

Here are some basic ideas, based on my experience, for organizing a program of mental health care reform: 

1) the expenses involved in the reform program should always be transparent, especially in a public institution.   If consultants or experts are brought in to give presentations to the group, it should be clear to everyone, including the public, how much money was spent on their travel expenses and any other compensations.   Catering and room costs should be made clear.  And most importantly of all, if there are 100 helping professionals who spend 3 hours at a meeting, it should be made very clear that this represents a cost of 300 person-hours of  care.  That is, 300 people could have had a 1-hour therapy session or evaluation.  30 people could have had a basic 10-session treatment for depression or an anxiety disorder, which could possibly have saved lives.  

2) critical debate should always be welcomed.  If there are experts in the group, their expertise and experience should be shared.    If a visiting expert is flown in, the group's responsibility is not to simply compliment the visitor, listen politely, and clap -- at a major academic institution, or anywhere else in society, there is a responsibility, a duty even, to engage in vigorous, intelligent debate, especially when there are critical issues about health, well-being, and morality, being discussed.  

3) it should be absolutely unacceptable for anyone working in the system to feel that their voice or opinion would ever be suppressed. 

4) consideration should be given, at a very high priority, to the morale and well-being of the workers, not just to the efficiency of the work.  

5) if there are to be catered lunches and time off given to staff for collaborative meetings, or to bolster group cohesion, then ALL the staff should be included, including the cleaning staff.   Most of us don't even know who the cleaning staff are.  

6) I have a very specific idea about the economics of care provision.  There are many underemployed counselors in the community, who often have to spend a lot of money renting private office space.  Many can't make it, and end up working in some other field.   But there is a lot of office space vacant in large institutions or campuses during evenings and weekends.  This space could be offered at a very low or free lease rate, to increase the number of hours of care available for people in the community.   This would be a win-win situation for underemployed counselors as well as for the community of people in need of more care.   Clinical office space should be provided with a much higher priority than administrative office space, particularly when there is a severe shortage of clinical care.  

For salaried care workers, I think that a blended payment model (that is, baseline salary plus some component of "fee for service") would be very efficient to increase care provision.  Some workers (counselors or doctors) might want to work longer, or less typical,  hours, and I am quite certain that there would be a high demand in the community for these extra hours.  But there would have to be a fair and convenient model of compensation.    Current salary schemes do not allow such flexibility.  


If you are interested in mental health policy, I encourage you to use your voice,  to be aware of changes going on in your community, and to get involved in the reform process. 

Review: Sex at Dusk by Lynn Saxon

I read this book a second time recently.  

I appreciate that such a scholarly and well-researched text was written by an amateur scientist.  It was written as a critique of a more popular book with a similar title.  This other book attempted to make a case that humans in the pre-agricultural era (i.e. over 10 000 years ago) had a much more promiscuous lifestyle, which for them was supposedly healthier and more peaceful--then with the implication that we should try to emulate this in modern society.  

Saxon's book looks at almost every claim made by the other authors, and shows how their analysis was biased, incomplete, or just completely wrong, in terms of historical and anthropological data, as well as genetics and evolutionary biology.  Saxon shows that the authors of the other book particularly do not address the very dark side of almost every case study described.  The areas of focus in both books include social and sexual behaviour in primate species most closely related to humans (chimpanzees, bonobos, and gorillas), as well as cultures of remote present-day groups, such as those living in the Amazon.   A particular emphasis is the genetic basis (through natural selection) of behavioural traits.  

The subject of the genetic foundations of animal behaviour, and of the mechanism of evolution through natural selection, should be part of everyone's common knowledge.  Books by naturalists, biologists, or geneticists on this subject are not only informative from a scientific point of view, but are fascinating in the same way that watching a good nature documentary would be:  most of us are unaware of the life cycles and behavioural patterns of most of the species with whom we share the earth.  The stories, often about species that many of us have never heard of, but also sometimes about familiar species, are almost always interesting, but sometimes shocking or disturbing or intensely dramatic.  The best science writer in this genre is Richard Dawkins -- whether or not you like his philosophical point of view, it is essential and often entertaining reading to learn about other species, with the eye of a great naturalist.  

Saxon shows that we cannot escape some of the problems which exist in relationship and sexual dynamics in humans, including jealousy.  There is a strong genetic foundation for pair bonding in our species, though not without tensions, jealousies, and strong desires, which differ between the sexes, to have other relationships outside of the pair bond; but such excursions outside of a pair bond cannot occur without a substantial cost, often manifest in behaviour which is in part genetically determined.  

None of these genetic factors justifies a social policy which constrains relationship choices... social and relationship freedoms, as well as guaranteed personal rights, are aspects of social justice that have thankfully grown in our country in the past century; they must be created and legislated, whether or not they have always been favoured in our species through genetic/natural selective forces in the distant past.  

Review: Capital in the Twenty-First Century, by Thomas Piketty

 Thomas Piketty is a French economist, whose book "Capital in the Twenty-First Century" is a great analysis of the history of wealth, economic inequality, and taxation through the past two centuries, focusing especially on Europe and North America.  

I highly recommend this book.  It is very long and detailed, and much of it is hard to understand fully for a person not experienced in economics or finance.    For a brief introduction to Piketty's work, there is a good documentary with the same title, which is also worth watching.  But the documentary does not contain nearly as much detailed analysis of the problems and proposed solutions, compared to the book.  

This book is important to read, to become familiar with these issues.  We all pay taxes, and most of us complain about them, but few of us understand the history of taxation, and the reasons why taxes are the way they are.  Even for those who are experts in the area, it seems to me that relatively few people (such as economists) have a good understanding of economic history.  

Piketty shows that income inequality was extremely high in the 1800s in Europe, leading to some people with enormous estates, while much of the population lived near or below the poverty line.  Most of the wealth in the society was owned by a very small number of people.   This changed dramatically mainly as a result of the world wars, and the resulting policy changes after the wars.  

Prior to the wars, those with enormous wealth paid very little tax, and this wealth was also passed through inheritance with very little tax either.   After the wars, progressive taxation of income and estates led to a large improvement in this type of extreme inequality, and allowed a much larger number of people (such as those in the middle class) to own a larger portion of national wealth.   

Interestingly, the United States in the 1950s-1970s had one of the most fair and progressive taxation schemes in the world, leading to improvements in economic inequality, before regressing substantially in the 1980s and beyond.  

Piketty shows that there are not only political and social consequences of having a society allowing extreme wealth to accumulate for a small number of people, without those people having to earn this wealth through work, there is also an economic consequence, since economic efficiency is not well-served or incentivized this way.   

His suggested solutions to this problem include having a progressive income tax, a progressive tax on estates & inheritance, and a progressive tax on capital or total personal wealth.  By progressive, he means paying a higher rate for higher levels of income, and a lower rate for lower levels.  At present, there are many examples Picketty shows where the system is not progressive, but regressive--that is, people with extreme levels of wealth actually pay an overall lower marginal rate on their vast incomes, compared to those in the middle class.  

The main barrier to a progressive tax on capital (i.e. a tax on invested fortunes), is that such investments are often hidden; many extremely wealthy people hide their wealth in offshore banks, etc. so it is hard for governments to understand how much wealth there is.  These are so-called "tax shelters."  In order to solve this problem, governments across the world would have to come together and cooperate with sharing banking information, to create a type of global wealth census, or "cadastre."  

How is this relevant to psychiatry?  Economic issues, including poverty, are extremely important in the causation and management of mental health problems.  Universal health care, and universal comprehensive education (including university  college, or other training) is possible in all countries, and can be improved where it currently exists, such as in Canada.  But health care is expensive, and needs to be fairly subsidized.  Taxation issues obstruct the provision of efficient social services, including health care.  

Also, greed in general, without a principle of making social or community contribution, is a factor contributing to declining mental health, and to more social problems including crime.  

I did not find Piketty's analysis or recommendations to be "radical" at all.  They are not in opposition to free-market economics, but rather are supportive of a system where markets could be free for all, without rapidly escalating and uncontrolled excesses.  

COVID-19, Psychiatry, and Politics: an update and reflection on 2020

 COVID-19 update January 2021

I come to this issue as a psychiatrist.  I am not an infectious disease specialist, immunologist, virologist, or epidemiologist.  But I am well-educated in all of these fields, at least to an undergraduate and MD level,  boosted further by my background in mathematics & statistics.  As an undergraduate science student another of my special interests was microbiology. I have always tried to follow developments in general medicine and medical research over the years, alongside developments in psychiatry.  Epidemiology and the science of efficient, valid study design and data analysis are essential components of modern psychiatry.  

I also have personal experience with this issue.  A close family member nearly died of COVID-19 and most likely will have long-term serious health consequences despite having survived.  One family member works on an acute COVID ward.  Four other family members are physicians or nurses working in acute care medicine and are in close proximity to this issue in their practices.  Another close family member is a virologist, part of a Canadian team that studies COVID-19 and is developing another vaccine.  An increasing number of colleagues, friends, and patients have been affected by the virus.  

This bears no similarity whatsoever to any other infectious disease epidemic that I have seen in my lifetime.  It is nothing like the seasonal flu. 

COVID-19 is the worst public health catastrophe to have befallen the world since the great pandemic of 1918.  

There have been about 2 million deaths due to COVID-19 in the world so far.  This is a tiny fraction of the number of deaths that would have occurred if we had carried on as usual, as though this were an ordinary outbreak of the flu.  

Let’s imagine that we had not introduced any significant public health measures, and that we had treated COVID-19 like any other seasonal flu outbreak: 

The current understanding of COVID-19 mortality risk, of about 1% overall, would imply a total anticipated worldwide death count of 50 million if no public health measures had been taken to slow the spread of the disease, mostly over the course of one year.     That represents over 500 million years of life lost, equivalent to all the years of life lost from murders and other violence in about 20 years of time.  

But these 50 million deaths do not even begin to estimate the other impacts on the population that would have happened: 

Hospital wards and intensive care units would have been overflowing for a year or more, leading to many more deaths: people with other diseases and injuries would have been unable to access care, forcing healthcare professionals to let many people die without the curative treatments that otherwise would have been available.  Unfortunately we see this going on right now in many places of the world, including in Canada, despite the strong public health measures we have taken.   

Dealing with such devastating trauma would have caused many healthcare workers post-traumatic illness, in many cases for the rest of their lives.  Many workers would have had to leave their careers.  Many would have died by suicide.    For such workers, it would be equivalent to working on the front lines of a major war on a daily basis for an entire year.  Unfortunately, this is going on in many areas of the world, despite the measures taken.  

And, unlike other epidemics of viral respiratory disease, COVID-19 has a clear propensity to cause lasting tissue damage, not only to the lungs, but to other organs including the brain.  There would have been a much higher burden of  lasting or permanent disability as a result, if the disease had been allowed to spread unchecked through the population.  

For people who have shockingly had doubts about the severity of the situation, I have wished that they could visit the many patients in agonizing, suffocating respiratory failure on their journey to a nightmarish ICU stay.  Ironically, the good public health measures in many places have limited ICU overflow, so that relatively few people in these places know any friends or neighbours who have suffered this way—but because of this success, many poorly-informed people do not have a realistic understanding of the horror of the situation. 

The strict measures we have taken have absolutely been necessary to prevent the present catastrophe from being a hundred times worse.  

But the measures were not nearly enough, except in a few countries.  

It is fair enough to observe that if a vaccine, massive-scale testing,  or effective acute treatments had been impossible to achieve, it would have made sense to just let the disease gradually run its course, with just enough public health intervention to prevent the hospitals from overflowing.  

But most of us were optimistic enough to anticipate that a vaccine and other treatments would be developed over the space of months to years, therefore it was imperative to slow the spread as much as possible, not only to delay deaths and suffering, but to prevent them entirely and allow a return to full normality.  

Here are some thoughts of other measures that I think would have been necessary or helpful:  

1) One of the unique aspects of COVID-19 is its very strong age-dependent morbidity and mortality characteristics.  In young, healthy adults under 30, it is indeed usually (though not always) a mild or even trivial viral infection.  But with every advancing year of the victim's age, the disease becomes more deadly.  

This fact, in my opinion, could have been used to design some very simple basic research studies.  It would involve healthy young volunteers, fully informed of risk, to be exposed voluntarily to the virus in a quarantined, medically-supported setting.  The risk would be comparable to that of volunteers for military service. 

This would have allowed research to determine the exact effect size of measures such as mask usage, mask type, ventilation effects, and inoculum size, in determining rate of spread and severity of ensuing disease.  We would know exactly the likelihood of airborne spread, fomite spread, and direct contact spread, therefore guiding us about optimal preventive measures.  

Right now we have very good evidence about the usefulness of masks to reduce viral spread, but a prospective, controlled study in humans would show, beyond the shadow of a doubt, with the highest standards of scientific reliability, the exact effectiveness of widespread or solitary mask use.  When equipped with the unequivocal study data, governments could then have invested appropriately in mask manufacturing for the whole population (including high-grade N95 masks if needed).  

I suspect the results would have shown a significant but modest benefit of masks, with better effectiveness for higher-grade medical masks.  This could have generated a massive government intervention to supply such masks and mandate them for the whole population, using war powers of the government to compel industrial production.  

Such studies would also have shown, with absolute proof, the degree and length of immunity conferred by prior COVID infection, and also whether disease severity would be impacted by inoculum size.  If a smaller inoculum led to milder disease, this would be another reason to mandate mask use.    

Such studies would also have been ideal to quickly test treatment strategies.  The whole hydroxychloroquine fiasco, which the world saw earlier this year, could have been dealt with and resolved within a month or so, allowing us to move on more quickly to find other treatments that could have been more effective.  As it was, hydroxychloroquine became yet another issue tainted by propaganda, misinformation, and mind-numbing ignorance about how to conduct valid medical research.  

Such studies could have demonstrated the degree to which major ventilation improvements in indoor settings (such as with MERV-13 or HEPA filtration at a high number of air changes per hour) could have reduced the risk of viral spread, particularly when combined with modest distancing measures.   This would have allowed us to determine effective safety protocols for settings such as classrooms and restaurants, possibly allowing all of these establishments to operate more safely during the pandemic.  Alternatively, the data might have shown that safety would not improve much with these measures, requiring that such settings be at least temporarily shut down.  

The studies would also have had the benefit of most likely producing an increased number of immune individuals, thereby preventing participants in the study from ever spreading the virus to anyone else. 

A modification of this study approach, which should still be done, and is uncontroversial, is to do more substantial animal studies to demonstrate airborne spread characteristics and the effect size of ventilation improvements.  

2) Ventilation

Thankfully, mask mandates have become much more a norm, though this should have been done many months sooner.  

A relatively neglected issue, which could be simply addressed, concerns improvements to interior ventilation, given evidence that COVID is spread at least in part through airborne transmission.  If every classroom, workplace, restaurant, and home, had simple ventilation improvements (open windows, HEPA filtration, etc.) there could be a significant reduction in the risk and rate of spread. 

Each individual method (distancing, limitation of the size of groups and time spent in group spaces indoors, masks, ventilation, disinfection) has a limited effect size, but in combination, if done consistently, lead to much more substantial protection.   

3) Mass testing

The development of population scale rapid, frequent virologic testing could also have led to a rapid end to the pandemic, while allowing much more freedom to work & socialize.  If every person in the population was tested daily or weekly, every positive person could have isolated for a few weeks; this would rapidly have limited cases.  This approach alone could theoretically lead to the extinction of the virus.  I do not know what type of technological limitations impeded this approach, but it seems to me an area that was never developed as fully as it could have been.  I suspect the vast resources of the US science, technology, and manufacturing community could have led to big developments in this area, if the government response had been more normal.  

2) Media and Political Issues

I am ashamed to observe that most of the medical community, and in particular the psychiatric community, has not had the courage to comment on political factors which have led to immense, needless, catastrophic suffering for individuals, economies, and the world as a whole.  

Prior to 2021, Canada's southerly neighbour was afflicted by a devastating failure of leadership.  We are afraid to comment, as professionals, about psychopathic and narcissistic traits accompanied by staggering incompetence, ignorance, self-absorption, affective instability, almost continuous lying, and callous disregard, in a major political leader.  It does not require advanced therapeutic insight to see this--the behaviours were in plain view on almost a daily basis for years.   I am reminded of a cartoon or fantasy villain, with a team of minions, not unlike the villain from a "Batman" movie or a Tolkien novel, with just as much power, though with less intelligence or criminal aptitude.   I am also reminded of a caricaturized bully character from film, such as "Biff" from "Back to the Future."  

If similar behaviour had been going on in the partner of one our patients, I am quite certain we would come out and at least speculate directly about this with our patient, with a message of stern warning In this case, the "patient" is an entire nation, and the "partner" is an extremely unstable, abusive leader, but one whose demagoguery and propaganda have allowed a significant segment of the population to remain devoted, as though members of a death cult, sometimes to a fanatical degree. 

There has been a devastating barrage of misinformation and propaganda that has caused a bizarre politicization of simple community health measures.  In part, I attribute this directly to the leader, whose egregious incompetence and callous disregard has allowed what could have been an inspired, ingenious response from one of the world's great countries to devolve into utter chaos, madness, and mass death.  This behaviour has affected not only the US but the whole world.  The world's response to COVID has been set back greatly, because the world's leader in advanced medicine and scientific research has been suppressed, languishing in a cloud of needless chaos.  

The US could have engineered a rapid, massive research response, akin to the Manhattan Project, or the race to land astronauts on the moon,  combined with public health measures, to have emerged an inspired leader in this crisis, leading to decades of respect and appreciation from people all over the world, bolstering its image and authority forever.  Many of the world's greatest virologists and other health experts are American, and I can only imagine what sorrow, anger, and frustration they must have had this past year to see their country's disastrous and frightening response.  Not only has the response been catastrophic, the leadership is so steeped in denial about the gravity of the situation, and probably so ashamed of its incompetence, that it is trying to convince people that it was never a serious problem in the first place, that it was all over-blown.  It is like trying to convince people that World War II never happened (interestingly, the total number of deaths in World War II is comparable to the number of deaths that would be caused by COVID-19 if nothing was done about it).  

There are complex causes for this phenomenon, but one element of the problem is the polarization of news information found online.  It is very problematic when a group of individuals holding extreme or delusional views can all meet together on an internet-based forum or social media, and be exposed only to repetition and escalation of their beliefs.  In this way, it is again very much like the dynamics found in cults.  

What can be done about this?  It is a hard problem, but I hope that companies responsible for such polarization, such as Twitter or Facebook, can take much stronger steps to prevent their sites from magnifying extremism and polarization, while still honouring freedom of expression. 

Experts and leaders need to ensure that the entire population has access to good-quality information, and is not trapped in a "news bubble."  

Leadership change is of course a key requirement for problems of this type to improve.

Twitter and other news sites have had a negative effect on my own morale.  I have found that stopping news and Twitter exposure entirely for several months has been helpful.  I think that it would be sound mental health advice for all of us to severely limit the amount of time we spend watching news or engaging with social media.  Probably one hour per week would be a reasonable maximum.  Exposure to standard news sources, such as major world newspapers, should accompany any exposure to "news bubbles."   

In Conclusion: 

I was always an optimist about this problem.  I thought we should have had much, much stricter measures earlier on, so that we could have followed a course similar to New Zealand.  We still should do this, but it is like a forest fire: it is so, so much harder to control it if you have left it burning for a long time, instead of dealing with it properly at the beginning.  I  anticipated that we would develop better treatments or a vaccine sooner than expected, and I am relieved and delighted that this has come to be.  

But the pandemic is not over yet.  We should be fighting hard, with every possible public health measure, until the population is vaccinated.  Then the war will be won, and we can carry on with a more normal life again.  Despite the devastation, we will have learned a lot, and some of our adaptations and innovations will stay with us forever—for example, I predict many of us will continue to do much more remote or video-based work, often from home.  I hope it can be a time of healing, peace, and reconciliation, with preparations and changes put into place to prevent this type of disaster from ever happening again.  

The Next Crisis: 

The next crisis, or at least one of the big next crises, is an even bigger one, which is inexorably coming (it has been happening already for decades): it is environmental degradation and climate change. Unfortunately some of the same factors which caused catastrophic delays in responding to the COVID pandemic are now causing delays responding appropriately to the environmental crises.  We need to be acting now to do much, much more about this.  A starting point for education on this issue would be David Attenborough's documentary, "A Life on our Planet."  It is both a sorrowful, tearful account of the state of the world's environment, but also contains a message of hope and a call for action. 

There is always hope despite the severity of any problem.  It is important not to allow frustration, cynicism,  or despair to deter us from taking the actions we can to help.   

BC COVID-19 Update, July 18, 2020

The management of the pandemic in BC has been very successful, thanks to everyone's hard work and sacrifice over the past months.

Some of us, such as emergency room or ICU staff, ambulance workers, and staff at grocery stores, have had to take on much more risk than the rest.  We need to show gratitude for this hard work:  the 7:00 PM celebration every day is a small symbol of this.

However, since the restrictions have loosened, we have predictably had an increase in cases again over the past few weeks.

I think there is a significant risk that the cases could escalate again quickly.  Then we would be in the same predicament as in March and April, although I think we would be better prepared.

Here is what we can do right now to prevent cases from continuing to surge, and to maintain our hard-won gains against the pandemic:  

1) People need to wear masks whenever they are indoors around strangers.   This includes in grocery stores, shopping malls, and on public transit.   All staff in grocery stores should be wearing masks.

Masks do not eliminate the risk of contagion, but they very clearly reduce it enough to make a big difference.  Mask use has not been emphasized strongly enough by public health authorities.


I think that we should give free high-quality masks to everyone in the population.  These should be made available at the entrance to every business, and at transit stations.  A home-made mask is fine--anything is better than nothing.  A good medical-quality mask is better, and an N95 is best of all.  Masks are available for sale at retail outlets such as Canadian Tire.

The evidence that has accumulated over the past months has shown a much lower risk of contagion outside, including in groups.  So I am much less worried about the need for a mask mandate outdoors, although I continue to think that the more mask use the better, when around other people.  I do think that there should be a mask mandate for grocery stores, shopping malls, public transit, and other indoor spaces in which strangers could meet each other.  

2) Maintain social distancing, also known as "physical distancing."  The farther you are from an infected person, the smaller the risk of contagion.  During the whole pandemic we have recommended 2 metres, or 6 feet, of distance between people.  I recommend this as a bare minimum.  The more distance, the better.  Social distancing is absolutely crucial if you are in an indoor environment.

3) Grocery stores and other businesses should continue to limit the number of people allowed inside at one time.

4) I think that if you are going to a restaurant, you should take out.  Sitting inside at a restaurant is a needless high risk activity.  The thought of opening bars seems like madness to me.

The evidence in the past months has also showed that the main route of contagion is through respiratory droplets.  There may be a small degree of true "airborne" transmission, but most spread is through close contact indoors with an infected person.  Many such infected persons do not have any symptoms, so there would be no way to know you are in contact with someone who has the infection.

The risk of such spread is greatly increased when people are talking, shouting, or singing, and the probability of contagion of course increases with the duration of time spent in a high-risk environment.     So a restaurant meal indoors around strangers, all of whom talking and laughing without masks, is very high risk.  The ventilation system in such an enclosed space can cause contagion in people downstream with respect to the air flow.

5) We are enjoying more social contact with friends and relatives, but we should continue to maintain a limited social "bubble."  Now is not a time to be inviting new friends to your home, or having dinner parties.  If you want a social dinner, consider having a picnic or a barbecue outside.

6) Hand-washing practices and cleaning surfaces such as doorknobs or shopping carts, are still recommended, but my reading of existing evidence is that contagion from surfaces (so-called "fomite transmission") is not likely.  The main mechanism of spread is through respiratory droplets in the air, spread by coughing, sneezing, talking, or simply exhaling.  Therefore, we should maintain good hand-washing practices but we do not need to be as worried about this, and we do not need to frantically increase efforts to sanitize surfaces.  Our efforts should be spent primarily on reducing contact with strangers, reducing contact with crowded indoor spaces, increasing mask use, and maintaining social distancing.

7) Working from home should be encouraged whenever possible.  An office workplace, with people in close proximity without masks, is very high-risk in my opinion.  Government support should continue to allow working from home, and financial support for people who need to take a leave from work.

8) I do not support any plan of students returning to attend classes indoors.  If there could be group activities planned for outdoor learning, in conjunction with video lessons from home, this might be a reasonably safe balance.

9) On a community level, the more we can increase testing and tracing, the better we will be able to control, or even end, the pandemic.   We can learn from other places that are controlling the pandemic very well, such as South Korea and Germany.   For example, if a home-test kit was available, manufactured with massive government-supported investment, freely provided, and if every person in the population could test themselves weekly, we could rapidly isolate almost every COVID-19 carrier, and the pandemic would be over within a month or two.  Such mass-scale testing is far from being available, but this thought experiment demonstrates how incredibly important it is to test as much as possible, including random people in the population, and people without symptoms; from there it is essential to have a system to isolate every person with a positive test as quickly as possible, as well to inform and temporarily isolate any known contacts.  This system takes leadership, organization, a vast investment of money, commitment, and hard work to set up and run. 

10) Follow reliable sources for information.  In BC, we are fortunate to have Dr. Bonnie Henry, who has been a great leader through this emergency.   There are good people to follow on Twitter for COVID-related information:  for BC news, there is @BCGovNews.  I recommend Eric Topol (@EricTopol), Max Roser (@MaxCRoser), Nicholas Christakis (@NAChristakis), the Canadian ID physician Isaac Bogoch (@BogochIsaac), David Boulware (@boulware_dr), @AndyBiotech, and for some more sophisticated virology, Professor Akiko Iwasaki (@VirusesImmunity).  There are many others, but I think these are a good start.

15 Average Years of Life Lost for each COVID-19 death

The following is a very rough estimate, which would be subject to refinement or correction, but I believe it is reasonably accurate.  

Here are some calculations to show approximate average years of life lost for each COVID-19 death in the population.  They are based on mortality statistics of COVID-19 deaths, 

which shows that about 49% of people dying were age 75+ (each of whom lost 6 years of life on average); 25% of people dying were ages 65-75 (each of whom lost about 15 years of life on average); 22% of people dying were ages 45-64 (each of whom lost about 30 years of life on average), 4% of people dying were ages 18-44 (each of whom lost about 55 years of life on average), and 0.05% of people dying were younger than 18 (each of whom lost about 70 years of life on average).  

Therefore the average years of life lost for each COVID-19 death is 

(0.49 * 6) + (0.25 * 15) + (0.22 * 30) + (0.04 * 55) + (.0005 * 70) = 15.525

So each COVID-19 death in the population leads to an average loss of 15 years of life.

The calculation is based on tables of COVID-19 deaths by age, all of which give quite similar numbers, combined with life expectancy tables (in this case from Statistics Canada).  

The US population therefore, in just 4 months time has had about 1.5 million years of life lost from COVID-19 (probably an underestimate), which is about as many years of life lost as from all the murders in the US in 2 years' time.

Reference for murder YLL statistics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607680/

Update:  through the course of 2020, there were about 375 000 COVID-related deaths in the US, representing over 4 million years of life lost, which is a similar impact on the population as  all of the murders in over 5 years' time.

6

Why strict social distancing and massively increased testing are important to solve the COVID-19 problem

There are various clear arguments about why social distancing is important in managing the pandemic.

Most would agree that obviously  distancing will reduce spreading.  But many people might wonder why it is necessary to continue social distancing even when case numbers are dropping, or when the situation appears to have improved, especially when distancing measures are causing such hardship.

When considering any sort of physical system or intervention, it is often interesting, logically, to consider what happens when an intervention is applied at the theoretical extremes.

Thought experiment #1: the two hypothetical extremes of social distancing

The two extremes for social distancing would be the following:

case #1) every person on earth (all 7.8 billion of us) would maintain over 2 metres (6 feet) of distance from every other person on earth, continuously for the next 4-6 weeks.

case #2) every person on earth (all 7.8 billion of us) would have direct contact (maybe a handshake, a hug, and a kiss) with every other human on earth, all in the same day!

What would happen with each of these extremes, given current COVID-19 infections?

Case #1: with maximum social distancing, pandemic over in 6 weeks, with 10 000 to 100 000 deaths

In case #1, there would be no spreading.  Of the current 10 million or so people who might carry the virus at the beginning of the 6 week period, perhaps  0.1 - 1%  would die, which means 10 000 - 100 000 deaths.  This is the lowest possible number of deaths from the pandemic, unless a cure is found in the next 6 weeks. 

After that 4-6 week period, the virus would be gone, and COVID-19 would no longer exist in the human population, unless it was introduced again from animals.  The pandemic would be permanently, completely over.  A variety of other human diseases would probably be greatly reduced as well.

Case #2: with maximum social contact, pandemic over in 6 weeks, with up to 160 million deaths

In case #2, everyone would contract the virus.  The death rate would be higher than case #1 since health care resources would be massively overwhelmed.  Let's say a  2 % death rate, which means 160 million deaths, all over a 1-2 month period,  which would basically be the worst devastation in human history.   After this point, the virus would also most likely be done, people would probably be immune, and the pandemic would be over.



We can see by comparing case #1 and case #2, which differ only in how much social distancing took place, that social distancing has a clear , huge effect on mortality.  The maximum effect of social distancing alone would be to reduce deaths about a thousand-fold and to put an end to the pandemic.

Conclusion: By social distancing alone, it is possible to theoretically end the pandemic in 6 weeks, with a minimum of fatalities.  But of course such a plan would prevent most normal activities in society for over a month.


Thought experiment #2: the two hypothetical extremes of testing

The two extremes of testing are as follows:

case 3) Every person could instantaneously know if they were a viral carrier, at every moment.  An imaginary device to accomplish this would, for example, be an electronic monitor that everyone would wear, that would instantaneously light up if a virus was detected in someone's exhaled breath.
A watered-down version of this, which is theoretically possible at present (if not feasible at scale yet), would be to have every person in the population tested every single day, with results available in minutes.

case 4) No testing at all would take place.  This is not far from what is really happening in some places.

What could happen in each of these cases?

Case #3: with maximum testing, pandemic over in 6 weeks, 10 000 to 100 000 deaths, with minimal disruption to daily quality of life

Every person with virus detected could promptly isolate, eliminating any chance of spread.  Since the tests would be done continuously on all people, there would be no chance for asymptomatic spreading.  The mortality result would be similar to Case #1 above, with the pandemic over in 6 weeks, with under 100 000 deaths.  But unlike Case #1 above, Case #3 would only require a 6-week isolation of the 1% or so of the population which carries the virus.  The other 99% of us would be entirely free to live normally, with no social distancing required.

Case #4: with no testing, pandemic over in years, or never over, with 4 million deaths 
With no testing, we would have gradual spread to the entire population, occurring over a period of months to years.  It would continue spreading because of asymptomatic transmission.  We could assume a lower death rate than case #2, since the health system would be less overwhelmed, and there would also be more time to develop better treatments.  So let us assume a 0.05% death rate overall.  This means about 4 million deaths.

Conclusion: testing, done as frequently as possible, and of as many people in the population as possible, has a clear, huge effect on mortality, on the duration of the pandemic, and on preserving a more normal quality of life.  Testing and isolating alone could also end the pandemic in 6 weeks, with a minimum of life or economic disruption.


What conclusions can we take from these hypothetical thought-experiments?

Social distancing obviously works.  The logic above shows it.   It needs to be extremely rigorous and disciplined, with everyone participating, in order for it to help best.  If some people are not participating, the virus still has a chance to spread.

There are actions that will increase the effectiveness of social distancing, to “magnify”  it if you will.  These actions include widespread face mask usage, plastic barriers, hand-washing, and frequent disinfection.

Frequent testing also works.  Experiments are not necessary to prove this.  The logic outlined above proves it!  With a maximum of testing, the pandemic could be over in 6 weeks, but unlike the social distancing technique, it would require much less disruption to the population, to lifestyle, and to the economy.

In practice, we are imperfect people, our governments are very imperfect, and also the technology required to put these two types of ideas into place are limited.  It takes time and money to manufacture test kits and to develop the infrastructure to distribute or administer them, and to arrange to isolate every positive.

What can we do in the meantime?  Individuals do not have the power to make more frequent testing happen.  But individuals can adhere to social distancing with as much discipline as possible.  This clearly will help.

What can businesses, schools, churches, and other group organizations do?  They can enforce rules of social distancing for their employees, students, or members.  They can sponsor campaigns to persuade others to follow the rules.  They could use their political influence to urge governments to do the same.

Industries could participate, to the best of their ability, in the mass-manufacture of testing kits if possible, and of other useful technology, such as masks.

Governments have some power to enforce social distancing, and in my opinion they should use it, if they want the pandemic to end sooner, to save more lives, and to get the economy going sooner.
Governments and industry also have the power to maximize the production and deployment of tests.  If the number of tests could be increased 10-fold, or 100-fold, or 1000-fold compared to where they are now, this will put a very powerful brake on the pandemic, and give us the chance to eliminate the virus entirely, with the smallest possible disruption to our lives.    Really, I don't understand what they have been waiting for; every day of not maximizing test kit production is a day of needlessly careening towards greater and greater catastrophe and death.


If both distancing and testing are done in a non-committal, half-hearted, slipshod manner, then there will be probably some reduction in case numbers, a "bending of the curve," but the pandemic will drag on possibly for years, or until a vaccine is found to work, is mass-produced, and given to the entire population.

There are, of course, other things to work on towards solving the COVID-19 problem, especially vaccine development.  But this is likely to take quite a long time.  It would be unprecedented for a new effective vaccine to be available within a year.  But then, I am always amazed with what human ingenuity can accomplish, so I wouldn't be surprised if a good vaccine is indeed developed in record time.

There is also the hope that new, more effective drug treatments can be found.  This research is just beginning to hint at some more effective developments.  I wouldn't be surprised if much better drug treatments will come along in the next months as well.

COVID-19 update April 5 2020

The main advice about COVID-19 is just the same as before:  very strict social distancing (stay at least 2 metres, or 6 feet away from other people at all times), stay at home as much as possible,  wash your hands very thoroughly after touching anything that someone else might have touched, and do not touch your face unless your hands have been very carefully washed.

Please keep in mind that the 2 metre or 6 foot social distancing guideline is an arbitrary recommendation.  It would clearly be more effective to have 4 metres of social distancing!  The 2 metre recommendation is a starting point, but it would be best of all to avoid all crowds entirely, and even to avoid places which have been crowded in the previous hours (especially indoor places). 

These measures alone are helping to contain the spread of the disease, but we need to keep this up for many more weeks or months.

It has become clear (unsurprisingly) that disease spread can be significantly reduced if as many people as possible are wearing masks, especially in crowded places such as grocery stores or public transit.  Masks probably are most effective to prevent a person with COVID, including the many people without active symptoms, from spreading it.  Therefore, mask usage, if it is to be optimally effective, has to be used on a massive scale.

However, we have a terrible shortage of medical masks.  So it will be necessary to make home-made masks, or use scarves, until we have an abundant supply for the public of medical masks.  Medical masks need to be prioritized for medical workers, community workers, transit drivers, and grocery store staff.


It is valuable to look closely at what China, South Korea, and Taiwan have done to get their COVID-19 infections under good control.  We should be well-informed about their strategies, and copy.  Generally, my impression is that their strategies are similar to what we are doing here, but much more strict and enforced.

One of the issues of the week has to do with hydroxychloroquine and azithromycin as possible treatments for COVID.  The only evidence for these comes from so-called "in vitro" experiments; there is not yet any supportive evidence for their use in people with COVID.  But it is still important to study the question, which has to be done in a randomized controlled fashion.  Results of this research will take weeks.   I am neutral on this question, as we have no good evidence to guide us one way or the other on it, except for a recent negative study showing that it is not useful in severely ill patients.  It remains to be studied whether they could be effective if given early in the disease process, or prophylactically.   It is very clear that these drugs should not be endorsed, as they have potentially dangerous side effects.  And the public focus on this issue in the U.S. may distract people from focusing on what actually IS proven to help, which is social distancing, staying home, hand washing, and mask use.

I have thought of a modification of my "COVID hotel" idea, (see https://garthkroeker.blogspot.com/2020/03/covid-19-management-brainstorm-ideas.html) which is much less controversial.  It would seek participants for the hotel from a cohort of people working in high-risk zones, such as hospital staff, emergency response workers, and grocery clerks.  A cohort of several thousand such people would be followed closely, with a COVID test being given daily.  There would be no inoculation--each person who ended up with COVID would have acquired it in the course of their work.  Every person with a positive test would be promptly enrolled in the COVID-hotel study.  The advantage of this technique compared to present research studies, is that we could be guaranteed that every participant had become positive within the previous 24 hours, therefore would all be in an equivalently early stage of infection.  I hypothesize that any treatment intervention (such as an antiviral drug) would have the best chance of working if given as early as possible in the infection process.  Since everyone in the study would begin treatment at the exact same stage of infection, it would greatly reduce variability in outcome simply due to giving the drug at a different stage.

Mental Health care during COVID-19

With COVID-19, we are all likely to experience great hardships:  social isolation, cramped living quarters, severe financial problems, daily anxiety about going outside, difficulties with simple activities such as getting groceries or basic supplies, and of course the awful horror when we learn about what is going on elsewhere.  "Elsewhere" for now may be an abstraction about some city far away, but at some point "elsewhere" will get closer to home, to our families, to our loved ones. 

Symptoms of all mental illnesses have a high chance of becoming more severe.  

What can we do?  

I don't have the answers.  I'm scared myself.  

But here are some reminders about the basics: 

1) to the best of your ability, eat well, sleep well, and get some exercise, every day.  Try to have a schedule about doing these things.  It may not be possible to get these things done.  Normal sleep may be impossible due to anxiety.  But try.  Have a schedule.  Do your best.  Avoid things that make you worse emotionally, such as too much caffeine, too much junk food, etc.  

2) Try to focus on something else other than COVID news.  Read.  Study.  Clean.  Play video games.  

3) Have social contact.  This would have to be on the phone, by email, by Skype or FaceTime.  Or you could talk or sing to people who live nearby, as they are doing in Italy.  

4) Plan for what you'd like to do when this is all over.  It could be brief, over months, but maybe this could drag on for a year or more.  Think of the great celebration we will have then.  

COVID update April 3, 2020

As the pandemic progresses, we see more and more abundant evidence that very strict social distancing is effective.

2 metres (or 6 feet) of social distancing means that if both you and a person next to you have your arms extended, stretched out as far as you can reach, you should not be able to touch the other person's fingertips.


As expected, mask use is gaining more clear evidence.  Probably the greatest benefit of wearing a mask is to prevent the mask-wearing COVID-positive person (including the many people who are carrying the virus but not yet showing obvious symptoms) from spreading the virus to others.  Therefore, to be most useful, everybody should be wearing masks, particularly in crowded places such as grocery stores.

I have updated my idea about a voluntary inoculation technique: https://garthkroeker.blogspot.com/2020/03/covid-19-management-brainstorm-ideas.html
The risk of this technique would be that some of the volunteers would face a risk of death or permanent injury.  But the benefit of the technique would be that a cohort of people would leave the technique in a proven immune state; and the technique would allow much more rapid research (done in the most perfectly rigorous blinded randomized-controlled manner) to establish clearly and in the quickest possible way whether proposed antiviral treatments work or not.  I suspect most antiviral treatments would be much more effective if given in the earliest stages of infection, rather than after severe symptoms have developed.  This is true of other antiviral treatments, such as acyclovir for HSV.  This technique would allow a guaranteed method of testing whether such antivirals would make a difference for people guaranteed to be infected but who are in the earliest pre-symptomatic stage.  In getting these answers quickly (saving weeks to months of time), tens of thousands of lives could be saved as we determine much more quickly which treatments actually work and which do not.  Not only could it identify effect sizes of effective treatments rapidly, it could also give us the information which would lead us to stop  offering putative treatments that may actually be harmful.

Meanwhile, I continue my advice to keep up social distancing.  Wash your hands very thoroughly and frequently, with an extra time whenever you have touched anything that anyone else might have touched.  Learn about good hand-washing technique.

Mask use has strong evidence.  But there is a shortage of masks for those who need them most.  So people will have to improvise their own home-made masks.

I encourage keeping some disinfecting cloths with you.  Clorox wipes are in short supply, but you can make your own by cutting up some old clothes into rags, and storing them in a glass jar containing a strong antiseptic such as Mr. Clean.

Avoid going out unless it is absolutely necessary.  I do consider daily exercise necessary, but if you do this, choose a time when fewest people are around, and a place where there is the least crowding.  I suggest sunrise or midnight.  Of course, be mindful about other safety risks.

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.

Review: "The Coddling of the American Mind" by Lukianoff and Haidt

The Coddling of the American Mind:  This is another book I recommend as an important, timely review of contemporary issues relating to modern culture, parenting, free speech, and university education.

I respect what I think Haidt is trying to do, as a persistent theme in his career:  to be a peacemaker, to encourage intelligent, harmonious, respectful dialogue among people with different viewpoints or political leanings, and to reduce or mend hostile polarization.  This theme comes across once again in this book.  I could not support this goal more strongly.   Haidt is probably one of the few psychologists who would have a respectful audience among people right across the political spectrum.

But there are many areas where I disagree.

Safetyism -- A Culture of Fragility

The initial section discusses how in a well-meaning quest for "safety" we can create a culture in which people are weaker, less capable, and more fragile.  For example, if we are so afraid of a child falling down and getting hurt, we might not allow bike riding, climbing, gymnastics, etc.  But this lack of exposure to challenging, slightly risky activity would lead to a failure for the child to develop normal physical skills, and might also lead to the child learning to fear and avoid challenges, rather than to face them and master them. 

Ironically, this would sabotage the goal of improving safety. 

Intellectually, according to the authors, if we teach fear, avoidance, or suppression of disagreeable ideas and of the people who express them,  it may likewise lead to a failure to develop normal resilience or problem solving, and may foment unnecessary, destructive societal conflict.

So the authors are saying that just as we must allow children to try riding bikes or climbing, even though there is a risk of falling, we must encourage a cultivation of resilience and respect when exposed to disparate ideas, including those which offend us.

Cognitive-Behavioural Therapy (CBT) as an approach to modern life

The authors make frequent mention of cognitive-behavioural therapy (CBT) ideas, as a model for approaching these social and political issues.  The principles of CBT call for us to study our thoughts, assess them for possible distortions, be open to challenge them and test them behaviourally, and also to face our fears.

Extreme Examples, Case Studies

They describe a variety of unsettling stories of extreme cases, where so-called "safetyism" led to excessive negative consequences for scholars, for free speech, even for university culture in general.  The authors argue that these conditions cause intellectual freedom to be dampened, replaced by an atmosphere in which some professors may be reluctant to speak their minds or share their research, for fear of causing offense and a resulting protest or scandal. 

A decline in teen and young adult mental health?  

The authors move on to describe their theory that teen and young adult mental health is declining, and that a combination of  "safetyism," overprotective parenting and internet use (especially social media) are responsible.    One of their prescriptions for this (which they advise strongly near the end) is for parents to encourage so-called "free play" with a restriction of internet or smart phone use for children.

Misgivings

Here are some of my misgivings:

 As is often the case, one can make a general prescription for a cultural change based on knowledge or experience with a limited group (sometimes a group of just one, when we recommend to everybody what worked for us individually).   Haidt is a respected, famous academic leader who has a fair bit of influence.  His book is marketed extensively, as I suspect are the public lectures across the world.  It would be consistent with one of the better themes of this book to welcome some balanced and thorough debate about it.  One insight from social psychology is that once a person has publicly announced a position or opinion (especially in the form of a well-selling book) they are more likely to be biased in favour of this position, despite contrary evidence.


It may well be true that cultivating intellectual resilience through exposure to disparate intellectual ideas, exposure to risk, free play, etc. are in general good things, which would be reasonable public health measures or aspects of a healthy policy about parenting or education.  But such cultivation may require a different approach for different people, just as cognitive-behavioural therapy would need to be approached differently depending on where the individual person is at.

In CBT, as with any therapy, the process cannot be pushed if the person does not consent to it.  Exposure therapy (e.g. exposure to fears, challenging safety behaviours) cannot occur without informed consent, otherwise it would often be traumatic and counterproductive.  And exposure usually needs to occur in a controlled, gradual manner, which is quite different from the way stress occurs in the environment (such stress outside of a therapy room is usually random and uncontrolled).    And not every mental health problem is amenable to exposure therapy; in some cases exposure makes things worse.  Humans are not always "antifragile."

One of the reasons why I think there is more stress about conflictual issues on university campuses is not because the students are less resilient at all.  I think it is because universities in general have become more accepting and accommodating to individuals whose concerns would have been more dismissed and marginalized in previous years and decades.

It is possible now to attend university while having more serious mental health problems, and most modern universities are more accommodating than they were in the past. 

There are also movements for previously marginalized groups to speak out, and insist on their rights.  Such insistence, as we see from all previous civil rights advances through the ages, often does not happen without social stress and conflict. 

So actually I think students are at least equally, if not even more,  resilient, courageous, and brave than they were in the past.  They are not merely "coddled." 

It is not clear to me that there is a large change in rates of mental illness, over a long span of time.  There may be, but it is debatable.  There can be transient ups and downs over the span of years or decades.  Causes for these changes are probably complex, regionally variable,  and multifactorial.  Economic factors, such as poverty,  are probably very important and underappreciated.  Different rates may be due to different rates of reporting, more awareness in the population, different trends or fashions of diagnosis, etc.

And if there is a change in the prevalence of mental illness, it is by no means clear to me that internet or social media use is responsible (there are some important recent studies disputing the impact of the internet on youth mental health).   There are good alternative viewpoints--here's a link to one good article: *   Przybylski, an Oxford researcher, has published a recent study worth reading on this subject: **

It is certainly not clear that parental "coddling" is responsible for changes in teen or young adult mental health.    There is evidence on both sides of this.  Common sense would dictate that, just as with any other human behaviour, we should be careful with our habits, our parenting, and with how children are spending their time.

I do more strongly agree about one of the authors' points about modern parenting:   it is not healthy for children to be overscheduled, to lack free time, and to be forced at a young age to start academic preparations for admission to a prestigious university.  Childhood should be a time of relationship development, play, and freedom.  However, some individual children may greatly enjoy and appreciate extra academic focus instead of more "free play" -- I know I was one of those children myself.

About "coddling."   The authors include this word in the title of their book.    It is meant as a pejorative of course.   I don't like it.  "Caudle" is a thick, sweet, warm drink which is meant to be  digested easily or enjoyed by someone who is unwell.  The authors use the word to mean that we are overprotective of others, including our own children, to the point that we are causing harm, as though feeding "caudle" to people who aren't ill.

I agree that such overprotection can occur.  But many children actually do need more protection and parental supervision. "Caudle" is often useful and good.  Different kids develop at different rates.  Some individuals, for various reasons, never attain, and are unable to attain, the full set of skills they need (physically, emotionally, or socially) to function independently, despite maximal "CBT."    Such individuals have often been neglected, left behind, and excluded by the majority.  One cannot just make a blanket prescription to "let the kids play more."   As a specific example, various types of learning disorders and developmental variants (such as autism-spectrum phenomena) are permanent, and they cannot be resolved simply by pushing the students to face their fears; remedial help and accommodation are needed (I guess we could call this "coddling").    Social anxiety disorders, which are extremely common,  should be approached using CBT techniques, but it is unlikely that any therapy can "cure" social anxiety -- we also need to accommodate ("coddle") and value shyness, rather than just try to "treat" it. ***

"Safetyism" should not be criticized too much.  Accidents and injuries are among the most common causes of death and permanent disability for children and young adults.  Basic improvements to safety are an obvious, reasonable societal advance.   People complaining about "coddling" as an impediment to healthy development might criticize safety features at playgrounds, or of signs recommending safe practices or rules for games.   I don't think these things deserve criticism.  Safety features and play instructions can be helpful for many people.  For those of us who don't want or need these safety features, we can just ignore or defy them, unless they are incorporated into law (such as regarding seat belt or helmet use).

With respect to parenting, the most common situation I see in my clinical practice is of people who have not been "coddled" too much, but who have been neglected or mistreated by their parents.   This has nothing to do with how much "free play" has occurred.

A common cause of such neglect is of a modern lifestyle where parents are too busy or disconnected to play with their children.   The causes for this phenomenon include cultural trends in work and parenting; economic stress; and mental illness.  Most children can accommodate to this, and even thrive, but some cannot.   Some children would find endless hours of free play to be a torment.    It need not be considered some kind of parenting triumph to allow your child to walk to school alone at an early age.   (I do not consider walking alone to be risky--the authors are correct in observing that risks of abductions, etc. are extremely low, and should not rationally lead to walking children to school just for their physical safety.)  But physical safety is not the point.  Enjoying time and relationship with your child is the point!  If you have the opportunity to play with your child, or walk him or her to school, this is not some kind of harmful "coddling"!  It is one of the joys of life, leading to memories that both of you will savour for the rest of your lives.     And some children may need to be walked to school, to help them negotiate their anxiety or build their social strengths alongside a trusted adult.  This is ok too, and is not "coddling" except in the best sense of the word.

I in general support the authors' recommendations for being open to hearing and respecting opposing points of view, as opposed to shutting down opposing voices using angry protest.  However, perhaps this recommendation deserves some questioning as well.  For example, if one has signed up to learn genetics, and if there is a space and time for a visiting lecturer once per week, I think most would consider it bothersome to reserve this precious lecture time and student attention on entertaining speakers who deny the existence of genes or DNA.  Free speech may not require that every point of view should have equal access to a reputable and influential public forum.    Of course, this would lead to a question of who has the power to decide who gets access to this forum.  A default answer would be to say that in a democracy, it is the people who would decide, hopefully guided by the wisdom of experts.   But sometimes the experts could be wrong.  Or sometimes population trends could be unreasonable.   In these cases, I do agree very much with the authors in affirming a principle of calm, reasonable openness to dissent to be enshrined as a guiding principle, as it is in many nations' constitutions.  And it is also reasonable for everyone in the population to be acquainted with rational techniques for self-questioning, such as CBT.

I actually do find that CBT ideas are so prevalent now, that many college students are aware of the theory already.  Young people are intelligent and well-informed, for the most part.

My own recommendations:

First of all, I question my right to make any sort of recommendation.    I think it is better to be a little more humble and admit that there is quite a bit of uncertainty about all of these things.

For parenting, I think different children have different needs.  For some it is ok or necessary to "coddle."  For others, it is best to encourage a lot more "free play."  For many kids it probably doesn't make a whole lot of difference either way, and there could be leeway to simply choose the strategy that is possible for you, and that you and the kids enjoy the most.  I am a big fan of spending a lot of time with one's children, to cultivate a close relationship, to build strong, positive, happy memories.  Such memories are, in my opinion, strongly protective of lifelong mental health, and one of the most powerful sources of resilience that experience can offer (other sources of resilience are inherited, and have nothing to do with parenting).   They are also very satisfying for a parent, and probably are associated with healthier, happier aging.   In many cases, though, the memories have nothing at all to do with mental health per se.  They are just memories of time together.  In general, I prefer to have them rather than not.

Review: "The Righteous Mind" by Jonathan Haidt

I recommend this book.

In The Righteous Mind, Jonathan Haidt shows that different people have different foundations which underlie their moral judgments or beliefs.

 On the "left," the foundations of fairness and charity are more prominent.  On the "right," the foundations of loyalty and "purity" are more prominent. 

These styles or foundations may be propagated in culture or family upbringing,  but also are partly influenced by heredity (genes).  In the middle part of the book, Haidt argues that each of these moral foundations can convey improved survival or natural selective advantage to whole groups.   For example, a group which values loyalty very strongly as a moral foundation is more like to be cohesive, and therefore more resilient to various stresses, including warfare or internal discord.

Haidt concludes his book with a strong message that we should empathize with people or groups which have different moral foundations, rather than simply fight with them or view them as enemies.  He espouses the goal of befriending opponents, including those who have different political or religious beliefs or moral foundations.  Such friendship would then reduce extremes of polarization and conflict, and allow groups to move forward more peacefully.

I respect his thesis very much, of cultivating understanding and empathy for people or groups which have different moral, religious, or political beliefs than one's own.  In a psychotherapy environment, such empathy is required in order for progress to occur, even when the therapist may object strongly to aspects of the patient's behaviour.

But I have some criticisms of Haidt's thesis:


Haidt seems to disparage the importance of reason or rationality.  In a type of "straw man" argument, he suggests that "reason" without other moral foundations such as loyalty, is insufficient or even pathological.   He uses a metaphor of a person or a mind being like an elephant, a powerful creature guided by instincts and passions, with the "rider" of the elephant being our "reason" or logical faculties.  The "rider" is described as a recent evolutionary development, intended to serve the elephant, rather than rule over it.

He anticipates in the book that some people will disagree with him on this.  I certainly do.  I do not disagree that the development of sophisticated reason or rationality is a recent development in evolutionary history, that it indeed did develop in service to the "elephant,"  and that there are strong selective advantages for "non-rational" qualities, which remain prevalent in nature.  But the evolutionary presence of traits is not evidence of their high moral value.

Modern rationality is the foundation of the justice system.  Imagine a court system, a scientific lab, a factory producing safety equipment, or a spacecraft agency such as NASA, which would not hold reason as the highest foundation in its decision-making, but instead would consider "loyalty" or "purity" as most important.  Such foundations would, and often have, led to disaster.

I realize that some applications of reason may in retrospect prove not so "reasonable" after all.  Reason is always fallible, and can be the foundation of huge mistakes--not just technical failures due to mistaken ideas that were apparently well-supported at the time (e.g. the belief in medical remedies such as bloodletting), but also moral catastrophes.   But the process of reason requires it to be flexible, to monitor itself for mistakes, to be willing to make corrections when new information arises.  This differs from "loyalty" which is by definition resistant to change despite the arrival of new information. 

"Loyalty" could be considered a component of "reason" which requires a waiting period before acting on new ideas.  It could be like electing a senator for a 6 year term, with other representatives elected for 2 year terms.  The senators would be more resistant to rapid or erratic whims of a capricious populace, while the representatives would be poised to act more quickly; the two chambers would ideally lead to an effective equilibrium, sensitive to change, but not impulsively so.

I am not saying that "loyalty" or "purity" are unimportant, but they cannot be viewed as morally equivalent to reason, on some kind of equal footing, such that differences between people can be understood simply as cultural variation.

I was bothered in Haidt's book by his passing disparaging reference to "new atheists" such as Richard Dawkins, more or less dismissing the value of their ideas without acknowledging their wisdom or contribution.  There are major problems with these thinkers which warrant fair criticism, but they do deserve respect and attention.  This is ironically contrary to Haidt's best conclusion, which is to have some empathy and respect for viewpoints different from one's own.

I am more allied to scholars such as Steven Pinker or Paul Bloom, who are "rationalists" in their approach to psychology and morality.    But I have to admit that Jonathan Haidt is an important thinker as well, and deserves respect and attention.

Any author of a book has a tendency to have some inflexibility in their position afterwards, due to several psychological biases.  If you have publicly asserted a position, and have become famous for it, you are more likely to maintain it in order to appear consistent, even if there are good arguments against it.  There can be some degree of ego involved as well--people don't like to admit that they are wrong.  I wish there was a little bit more humility when scholars or experts assert positions on these issues. 

I am not an author (except for this modest blog), but I know that I have an ego as well, and I would have a tendency to defend positions that I have asserted, even when they may need to be changed or adapted.  I need to watch this tendency in myself, as we all do in ourselves.

In some cases, it may not be possible to have a friendly, empathic dialogue in a setting of conflict, oppression, or injustice.  Haidt does not explore this type of scenario adequately.  Friendship and empathy are neglected in the management of conflict and polarization, but it is important to acknowledge as well that some of the necessary forces of positive change and justice can be rather more difficult and conflict-ridden.

The Psychology of Meetings

What does psychology teach us about the components of an effective or positive meeting?

Daniel Kahneman described psychological dynamics in meetings, such that those who contribute first or most vocally tend to bias the discussion excessively. 

Quieter members of a group may have important contributions, but they are never heard.   

A majority view can tend to prevail.   Dissenting positions are often suppressed by peer pressure.

People can be afraid to express themselves, due to fear of consequences. 

Many speakers or presenters in meetings are lecturing about information that is already well-known to most or all of the members, therefore this type of lecture is arguably a very inefficient use of everyone's time. 

Suppression of dissent or counterargument is the most powerful and morally troubling bias in persuasion and group dynamics. 

Overt bias in group dynamics and suppression of dissent can occur in overt ways, such as with an authoritarian meeting style.  But there can be subtler mechanisms, such as when a presenter is charming, articulate, humourous, rhetorically skilled, and equipped with attractive visuals.  Good food probably helps as well.  We all enjoy such presentations, but it is important not to let our enjoyment cause us to shut down our critical thinking.  Otherwise, a presentation can be more like a marketing campaign, a revival meeting, or a political rally. 

One tactic to reduce this effect can be to ask members to offer their opinions or questions, anonymously if necessary, before the meeting begins, so that opinions are not suppressed by the social dynamics in the group itself.  It can be helpful if the leader of a group is the last person to speak, rather than the first. 

A related bias in many presentations is the "focusing illusion."  Here, a single idea, plan, or thesis is presented, perhaps with good rhetorical style, nice visuals, and strong supportive evidence.  This leads to a strong persuasive effect.  But if there is only one single idea, plan, or thesis, without presentation and fair discussion of alternatives, the audience will be unduly persuaded towards the single plan they hear about.   In some extreme cases, what may seem like a reasoned, balanced,  presentation may instead be more similar to a sales pitch or a political rally.  To prevent the focusing illusion, it is important to allow time in presentations for debate, counterargument, and alternative ideas.   Audience members should be strongly encouraged to think for themselves, to question, and to debate. Many audience members might be reluctant to do this, even if it is allowed, because they may feel it is rude or disrespectful to the presenter.

Another big problem in meetings has to do with the efficient use of time.  Sometimes an hour is spent on a subject which could have taken just a few minutes of focused attention.   In other areas of our lives, such as when we are listening to music, or watching a TV program, or reading a newspaper, we would rapidly divert our attention to something else if the activity was not useful or enjoyable.  But in most meetings you are stuck there, with no capacity to change the activity.

I find that the "cost" of meetings is often not acknowledged.  By cost, I do not mean the direct financial cost, which could often be zero (though not always, if there is rented space, catered food, or  lost income).    I mean the cost in terms of the other activities that could have been done instead.  For example, if the meeting is attended by 24 psychotherapists, the total cost of a one hour meeting is 24 "person-hours" of psychotherapy time.  The value of "24 person-hours" of psychotherapist time is equal to the treatment of 4 depressed patients with a course of CBT for 6 sessions each.   We should acknowledge the costs, and keep these 4 untreated depressed patients in mind as we sit through the meeting.

Another cost of a meeting is of psychological well-being of the attendees.  Many professional activities are psychologically neutral.  Others could be beneficial, because they lead to better group cohesion or social connection.  But others still could be demoralizing, depleting, or frustrating, if they have a negative dynamic.  They could add to the stress of the day, since other work  would have to be done later.  If the meeting is psychologically depleting then it would be harder to keep up with other work.

But of course, some meetings are effective, enjoyable, educational, and socially beneficial for individuals and groups.  They could help people and groups work more enjoyably and efficiently, could help solve problems in the work environment, and could help with creative planning for the future.  We need to find ways to have more of these!

While I am not normally a fan of using questionnaires extensively with  my patients, I have a simple suggestion for meeting management, based on some of the recent trends in psychotherapy research:  obtain and measure feedback data from attendees.  The absence of feedback can often give the impression that everyone feels ok with the process, and therefore there is no need to change.  Such data would need to be qualified, since the data gathering process itself involves a bias.  Reviewers of any service may be more likely to rate it more favourably, otherwise they might not have used the service in the first place.  For example, if you gather outcome data from customers at a fast food restaurant, you may get very positive reviews.  Such data should not be used as evidence that we should have more fast food restaurants in a community!  But with this proviso in mind, here is a suggested questionnaire for meeting attendees, to be submitted anonymously after each session, or after each segment of a meeting.    Each question could be rated on a scale with 0="not at all" and 5="very much":

1) I learned valuable new information in this meeting, which is likely to improve my work practices.
2) The presenter took too much time. *
3) Everyone's point of view was welcomed and respected.
4) Disagreement, counterarguments, and dissent were encouraged.
5) I got a fair chance to express my point of view.
6) The time spent at the meeting was worth the time, compared to my other tasks and duties which I missed due to attending the meeting. 
7) The meeting was a good chance to connect with my coworkers.
8) The presenter was articulate, engaging, and organized.
9) I enjoyed this meeting.
10) I was bored during this meeting. *
11) The process of this meeting was fair and respectful.
12) The meeting made use of time efficiently.
13) I would like more such meetings in the future.
14) There were instances of disrespectful or objectionable content in the meeting. *
15) The presenter, and fellow attendees, could be heard clearly.
16) The presenter and/or visuals could be seen clearly by all.
17) The presentation contained a lot of unnecessary jargon or needless complex terminology.*
18) The meeting began and ended on time, and stuck to the schedule as announced in advance.
19) The cost of the meeting (in terms of money and time) was acknowledged.
20) Personal information was requested of me which felt uncomfortable to share in a work setting.*

The starred items should be reverse-scored.  That is, for starred items, if you initially rate something as a "5" then it should be scored as "0."  The score could be summed, with a maximum score of 100 (a "perfect meeting" !)  and a minimum of 0 (the "worst possible").

I estimate an average score for most meetings in a relatively healthy organization would be about 60-70. 

Aside from only looking at the group average scores, it may be very important to look at the range of scores from all individuals, to ensure that outlier data is not just "dissolved" into the group average.