Monday, January 11, 2021

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.   

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