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Us, Interrupted: How This Internist Is Responding To The Impact Of COVID-19

Us, Interrupted: How This Internist Is Responding To The Impact Of COVID-19

Us, Interrupted is a series that focuses on public figures as well as professionals on the front lines of the COVID-19 global pandemic. During this unprecedented crisis, we hope these stories of vulnerability and resilience will help us move forward, stronger together.

Mark Shapiro, M.D., is an internist and the associate medical director for hospital services with St. Joseph Health Medical Group in Sonoma County, California. He is also the creator and host of the Explore the Space podcast, which considers the relationship between health care and society.

We spoke with Shapiro about working in the medical field during the COVID-19 outbreak and how it’s affected his work and personal life.

1. What was your life like before we learned about COVID-19, in terms of your self-care and maintaining a sense of well-being in and out of the hospital?

I was in a pretty good place balancing family life, my clinical and leadership work, Explore the Space podcast, and my own self-care. Keeping an exercise routine, good nutrition, reasonable sleep, and having fun were things I was feeling more and more comfortable with.

Read more in MindBodyGreen.

If America was a Patient

If America was a Patient

Let’s get clear on what the problems really are, then divide and conquer.

Recently I recalled one of the most crucial things I learned in medical school: the power of the “problem list.” Each patient came to us with a diagnosis, which was the reason for hospital admission. But as our attending made clear: the easiest and most efficient way to address the condition was to separate it into its component parts. It no longer becomes “let’s manage this patient with dementia,” it becomes “let’s sort out what the smaller problems are that make up the bigger challenge of treating this dementia.” We then understand how each smaller problem feeds into the larger one, which ultimately leads to appropriately managing the patient’s disease.
Tackling COVID-19 in America is an overwhelming and gargantuan task with no clear pathway, with everything so far pointing to failure. Much like how psychologists recommend “chunking” for learning, parsing out a big problem into a smaller set of problems helps us organize our thoughts, delegate tasks appropriately, all while making sure we’re not overlooking anything. It also helps us create contingencies and monitor progress.

If America was a patient, this would be her problem list and items to delegate:

1. Unclear case definition and endpoints
Infectious disease experts must help us more clearly define what a COVID-19 case looks like: the virus attacks the respiratory system, but other systems, like the gastrointestinal system, may also be affected. It also appears that the inflammatory response (how the body responds to the virus) as opposed to the virus itself, may be the primary cause of mortality, and this dictates treatment. Given that the tests available are imperfect, a negative test, in the presence of symptoms, should be treated as a presumptive case. Once a case definition is established as universal, it should further be stratified as mild, moderate and severe, with objective criteria defining each. Our metrics of response success must also be determined: COVID-19 is an unprecedented pandemic that is positioned to barrel through the U.S. and kill anywhere from 100,000 to 1 million people. Is a successful response one that cuts the most conservative projections by half? And are we more concerned about minimizing infections (of which most will be mild) or is the bigger priority to minimize the number of deaths?

2. Confusing public health messaging
Clear public health messaging is a challenge especially during times of uncertainty. Currently the messaging on whether transmission can occur through the air remains inconsistent between the World Health Organization, Centers for Disease Control, the White House, and state governments. This contributes to the spread of the “uncertainty virus” and mistrust, not unlike in a hospital when multiple teams are involved where medical errors are often secondary to communication issues, and was especially so with the case of masks. Groups like Choosing Wisely have disseminated some evidence-informed, best practices but clear public health messaging needs to be centralized. The White House should delegate one expert, ideally Dr. Anthony Fauci, to disseminate up-to-date public health information clearly and succinctly while also communicating uncertainties. Editors of major media in print and online challenged with this crisis will also play a key role in presenting consistent and reliable public health messaging. For months experts as well as the media underestimated the threat of COVID-19, and while contrarian views can help dissuade groupthink and tunnel vision, they risk undermining public health best practices and expert consensus. It is not a black swan. Rather, it was a dark horse: an underdog, one we were too blinded to see coming. We’ve seen dark horses before.

3. Insufficient testing
We need to clarify what we mean by “ramp up testing.” Tests should be two-fold: of secretions for the presence of the virus (presence/absence, and quantitative viral load data if possible) through a swab of the oral cavity and serologic testing for protective antibodies (which dictates prior infection, and likely protection) ideally with a fingerprick test. At this stage home-based testing might make the most sense, and it’s crucial to test a number of candidates against the gold-standard hospital-based test. An ideal test kit might have: a link to an online symptom checker, the swab and fingerprick test, and a self-addressed return envelope to mail back the test to a state lab. Once a kit (which would be priced at $0 to the public) is created, a partnership with Amazon (similar to what was struck in Canada) might make the most sense, given their warehousing and shipping capabilities, but we must ensure their delivery workers are provided with protective gear. Additional tests should be disseminated to homeless shelters. The tests won’t reach everyone, but capturing at least 75% of the population should be enough. As a metric we must set a benchmark for the number of Americans we want tested by April 30th.

4. No clear clinical pathway after a positive test
In China, positives were quarantined away from home. Had we organized early enough we could have used empty hotels for this purpose. Instead we should model symptom monitoring recommendations after asthma action plans, which are based on the traffic-light method. An expert committee — possibly from the American Academy of Emergency Medicine — could create a similar system (for instance, including symptoms like fever for a specific number of days, shortness of breath, and so on) so that those with a positive test know when to go to the hospital. We have enough data now, based on thousands of cases, to create this system.

5. Challenges with logistics, manufacturing, and procurement
While exciting, searching for a vaccine is not the biggest issue right now. Instead, it’s logistics, manufacturing and procurement, and this requires organized and thoughtful public-private partnerships. To be clear, the Defence Protection Act must be formally implemented with clear directions for the manufacturing of ventilators (ideally portable bedside ventilators as these would work better in make-shift hospitals without ready access to outlets), n95 masks, face shields, and gowns for healthcare workers. But currently this is highly decentralized which contributes to chaos: so formally involving the Defence Logistics Agency will also be key. Delegating these tasks to a few major companies who have the ability to manufacturer and ship their products quickly is crucial. We must also set clear pricing: a Forbes investigation recently found the inability to effectively negotiate contributed to the undersupply. Companies like Apple have people skilled at negotiation and procurement, and could offer their most skilled specialists to assist in ensuring we get supplies we need for the next 2–3 months, which appears now to be a focus. Outside the box solutions such as mask sterilizing systems should also be scaled up as well.

6. Lack of a universal policy, treatment, and end-of-life algorithms
We don’t have expert consensus on institutional infection control policy, nor treatment, discharge, or end-of-life best practices. As such, we should consider rapidly adopting a universal infection control policy modelled on Partners Healthcare and have an expert team, perhaps from the Society of Critical Care Medicine use the currently available evidence to create an algorithm for care, stratified by mild, moderate and severe. While imperfect, it will provided a road map that can be refined as we learn more, and would replace the informal crowdsourcing of best practices on social media. An ideal algorithm should dictate the parameters for oxygen, what starter therapies (medications and fluids) might help, criteria for mechanical ventilation (and settings), when to provide experimental treatments (e.g. chloroquine and remdesivir) for compassionate or trial us, and when to discuss comfort care. While abiding by infection control practices, everything possible must be done to allow family members to be present with their dying loved ones — walkie talkies goodbyes aren’t enough. Eack patient that enters the hospital with COVID should have an advanced directive regardless of how severe they are on admission. Given that some deaths have occurred after discharge, every COVID patient released from hospital must have a clear set of criteria on what to do at home, and when to return.

7. Unprotected healthcare workers & whistleblowers
Though doctors may be enlisted, many are struggling with their duty to serve, preparing their wills, and protesting seemingly to deaf ears for personal protective equipment (PPE). Thousands of healthcare workers around the world have died, including at least two resident doctors. The death of New York City-based Dr Frank Gabrin, himself a proponent for physician wellness, need not be in vain. We must have PPE for each healthcare provider, replaced at least once a shift, while also allowing for sufficient recovery time between shifts (in New York, having doctors and nurses serve from around the country helps with this). Punishing whistleblowers was seen first in China and but is creeping up in the U.S among healthcare workers and the military — this reprisal demonstrates a lack of psychological safety which will only worsen outcomes. Everything must be done to protect those that speak up.

8. Scattered research and no centralized database.
While it’s promising to see so much research on therapeutics happening all over the world — snippets shared over social media are mostly of case reports and small trials. We must create a central research database of existing studies — Stanford has a good starting model. Many research questions still remain. We could also leverage electronic medical record systems to help central database of diagnoses, clinical course, and outcomes.

9. Exacerbations of existing inequities
As with any patient, the social history cannot be forgotten. We need to get clear on what Americans with chronic health conditions should do if they can’t get care as they are at risk for dying due to lack of care during this crisis. We must also make every effort to protect and serve the most vulnerable who are at higher risk of poor outcomes — African Americans, those in the South, as well as the homeless and the undocumented (who may often be ‘essential’). Indeed as Alexandra Ocasio-Cortez tweeted last week, “inequality is a comorbidity.” It will be a stain on this nation if this crisis further perpetuates existing inequities. Ensuring healthcare during this time is accessible and universal, as recently underscored by the WHO is key, and could be inspired by other promising social experiments.

10. No clear plan for the “echo pandemic” of mental illness and social unrest
We are beginning to see an echo pandemic of mental illness and we may also see a rise in social unrest the longer we stay in lockdown. We must plan for both of these. To start, mental health experts should, where possible, offer services virtually. City planners must prepare for a possible surge in domestic violence, looting, and rioting. Notably, given the policy around face coverings, many perpetrators of public crimes may be difficult to identify.
This is America’s problem list; it is by no means comprehensive but it might be a starting point to help a strong leader delegate tasks. We can benefit from post-mortems from SARS and study the pandemic response now. As economist Daniel Kahneman popularized, we should also consider creating a premortem — anticipating how our response will fail helps us prioritize an action plan. The first step in any situation and assessment is realizing that one big problem is really a set of smaller problems and progress involves working diligently to address each component part. The intent is not to oversimplify but to make the task of battling COVID-19 more manageable while minimizing decision fatigue and maximizing public trust.

The time is now to divide and conquer. COVID-19 is not a drill. It’s a bitter pill.

**Originally published on Medium [visit for hyperlinks/citations]**

Us, Interrupted: How Uché Blackstock, MD, Is Taking Care Of Herself While Caring For Others

Us, Interrupted: How Uché Blackstock, MD, Is Taking Care Of Herself While Caring For Others

Us, Interrupted is a series that focuses on public figures as well as professionals on the front lines of the COVID-19 global pandemic. During this unprecedented crisis, we hope these stories of vulnerability and resilience will help us move forward, stronger together.

Uché Blackstock, M.D., is busy. She is the mother of two small children, the founder and CEO of Advancing Health Equity, and an emergency medicine physician working on the front lines of the COVID-19 pandemic in New York City.

We spoke to Blackstock about a life working in medicine during the pandemic, and how she’s balancing caring for herself, her children, and her patients during these unprecedented times.

What was your life like before we learned about COVID-19, in terms of your self-care and maintaining a sense of well-being in and out of the hospital?

To be honest, it’s hard to remember what life was like before the COVID-19 pandemic hit NYC. I’ve been immersed in the crisis for the last two weeks caring for patients in urgent care clinics in central Brooklyn. As a parent, practicing physician, and the CEO of my own consulting firm, I’ll admit that finding the time for self-care has been quite challenging for me. I try to eat healthy and to maintain a healthy exercise schedule. Before COVID19, I took up journaling, especially in the evenings to decompress before I fell asleep. I also consider self-care to be maintaining my connections with my loved ones and friends, so I try to be intentional about finding meaningful time to spend with them.

Read more in MindBodyGreen.

Us, Interrupted: How Writer Charles Yu Is Adapting To COVID-19 With His Family

Us, Interrupted: How Writer Charles Yu Is Adapting To COVID-19 With His Family

Us, Interrupted is a series that focuses on public figures as well as professionals on the front lines of the COVID-19 global pandemic. During this unprecedented crisis, we hope these stories of vulnerability and resilience will help us move forward, stronger together.

Charles Yu is a writer of fiction and nonfiction whose writing has appeared in numerous magazines and literary journals, including Slate, Esquire, Wired, and New York Times Style Magazine. He has also written for television, including HBO’s Westworld. Yu’s newest book, Interior Chinatown, was released in February 2020. His first book, How To Live Safely in a Science Fictional Universe, was named a New York Times Notable Book and listed as one of the best books of 2010 by Time magazine.

Here, Yu shares with us how he and his family are adapting to life during COVID-19: with exercise, getting outside, and maintaining connection with loved ones online, as well as the challenges of self-care during this difficult time:

1. What was your life like before we learned about COVID-19, in terms of your self-care and maintaining a sense of well-being?
It actually wasn’t that different from my life now. Since 2014, I’ve been writing full-time (after having been a lawyer for many years), and although I have worked in a number of TV writers’ rooms (for the past couple of years, I have been lucky enough to be writing scripts in development), I have been working from home.

My day-to-day routine is get up, walk my dog, pour coffee, and write. I tried to exercise at least three times a week, either a class or a 3- to 4-mile walk. My wife ordered some home exercise stuff (resistance bands and floor sliders), so we can try to get workouts in while isolated at home.

Read more in MindBodyGreen.

Us, Interrupted: How Soledad O’Brien Prioritizes Well-Being Amid COVID-19

Us, Interrupted: How Soledad O’Brien Prioritizes Well-Being Amid COVID-19

Us, Interrupted is a series that focuses on public figures as well as professionals on the front lines of the COVID-19 global pandemic. During this unprecedented crisis, we hope these stories of vulnerability and resilience will help us move forward, stronger together.

Soledad O’Brien is a powerhouse. As the CEO of Starfish Media Group, host of the show Matter of Fact, and an award-winning broadcast journalist, she is used to busy days. She also started the PowHERful Foundation with her husband, supporting women in their journey to higher education.

Here, she shares with us how she and her family are adapting to life during COVID-19: with schedules, long walks, and how it has affected her physical and emotional well-being.

What was your life like before we learned about COVID-19, in terms of your self-care & maintaining a sense of well-being?
I don’t think I was very good at self-care. I travel a lot for work, and it’s easy to get exhausted. I tried my best to get six to eight hours of sleep and avoid red-eye flights as much as possible. The main thing was eating well and trying to get enough sleep.

In terms of other aspects of my well-being, a big part of it for me was needing to feel “useful,” as in getting stuff done. I’m a box checker, and I’d feel good knowing if I got everything on my list done. I never found much relaxation in cooking, but I’d volunteer to clean up, for instance; that would help me feel like I was being useful.

Read more in MindBodyGreen.

My plea to corporate America to help us stop the spread of COVID-19

My plea to corporate America to help us stop the spread of COVID-19

Some of America’s biggest companies should consider leveraging their logistical capabilities—from using drive-thru windows for screening to turning megastores into diagnostic and treatment centers—as part of their corporate social responsibility, during these dire times.

Dear CEOs of McDonalds, Apple, Nike, and Marriott:

As you probably know, the success of both China and South Korea in decreasing the number of new cases of COVID-19 required both social distancing but also widespread testing and isolation of confirmed cases away from their homes. In other instances, testing even more aggressively made a big difference, and the World Health Organization now strongly recommends expanding COVID19 screening as well as isolation. Italy may have waited too long to implement crucial measures and North America has lagged behind for some time: estimates show that the US is now less than two weeks behind Italy and extremely behind in COVID-19 testing.

Testing is not widely available in the US and Canada, with the spread of misinformation leading symptomatic people to head to their local hospital or family doctor to try to get tested (with limited success while overburdening the system). It’s even more dire knowing that, in New York City for instance, an estimated 80% of ICU beds may already be occupied.

As powerful corporations, I hope you consider leveraging your own logistical capabilities, as part of your corporate social responsibility, during these very dire times—particularly in hotspots like Seattle, San Francisco, Toronto, Vancouver, and New York City. Here are some suggestions for what you can do during these perilous times.

Over the past week, McDonald’s announced they are closing seating. There are over 14,000 McDonald’s in the US alone, most of which have drive-thru windows.

So, my first idea involves pausing fast-food manufacturing for a few weeks in some of these outlets and using the existing drive-thru infrastructure for in-person fever screening (window 1) and COVID-9 throat swabs (window 2, if fever is present). These could be staffed with local nurses (wearing personal protective equipment, or PPE) who might typically work in community clinics that are currently closed. The brand recognition of McDonald’s means that most North Americans would easily be able to locate their nearest franchise. These would effectively serve as “Level 1” screening and diagnostic facilities for the next several weeks, with repeat testing weeks later to assess when an infection has cleared.

Second, over the past week, Apple (which has 272 stores in the US) and Nike (which has 350 stores) have closed their stores. Both of these stores, which maximize negative space and average several thousand square feet (so up to 4.5 million square feet of unused space), have design elements that may help reduce transmission during a pandemic. Some of these stores could be refashioned to serve as “Level 2” diagnostic and treatment centers, for more in-depth diagnoses and assessment of confirmed COVID-19–effectively “cohorting” positive cases together. Also, since both Nike and Apple have longstanding manufacturing relationships with China, with independent shipping and warehouse capabilities, they could help store any donated medical supplies from China and the country’s business leaders. Doctors who are not currently skilled to work in an emergency department or intensive care unit (for instance, most general practitioners) could administer the tests and basic treatment at these sites while wearing appropriate PPE, which offloads the burden on hospitals (which in turn serve as “Level 3” treatment sites for more advanced care). This could work better than military tents.

Third, China’s success in reducing transmission was in large part due to effectively quarantining cases away from their family (so as not to infect other family members). Yet building large quarantine centers, as China did, is not logistically feasible in North America. As such, now that there are fewer travelers, Marriott, which has wide reach across North America, could offer designated hotels in which to isolate the confirmed positives for 14 days to help induce “suppression.”

To be sure, North America should still follow the lead of both Britain and France by harnessing local manufacturing capabilities (which requires a Defense Protection Act), specifically for personal protective equipment like N95 masks, gloves, and gowns for first responders–this is even more crucial given the shortage. However, the bigger challenge will remain logistical. We may even end up having enough expensive equipment like ventilators (which may be used to serve multiple patients) if the milder cases are effectively identified and treated early.

I agree that “brands can’t save us” — but companies can leverage their strengths in collaboration with government. In fact, there have been countless examples from history of corporations pivoting to assist in public health challenges. The most prominent one that comes to mind is Coca-Cola. For decades, Coca-Cola offered its cold chain and other logistical capabilities to assist public health programs to deliver vaccines and antiretroviral medications, because donating money, simply put, just isn’t enough.

Through innovation, you’ve been able to place a thousand songs in our pockets, boast the largest market share of footwear, become the biggest hotel chain in the world, and serve as the most popular fast food company. Facilitating widespread screening, diagnostic testing, and facilitating the safe isolation and treatment of mild-moderate cases is not an impossible feat, especially if you work together with the healthcare system. Instead of allowing your brick-and-mortar businesses to sit idle please consider pivoting towards a solution in collaboration with government, as part of a coordinated and effective pandemic response.

Time is running out.

**Originally published in Fast Company on March 19 2020**

How artificial intelligence could improve global health

How artificial intelligence could improve global health

Canadian and international initiatives aim to apply AI to help solve global health conundrums

As we grapple with the coronavirus (COVID-19) pandemic, the pattern of viral spread may have been identified as early as Dec. 31, 2019, by Toronto-based BlueDot.

The group identified an association between a new form of pneumonia in China and a market in Wuhan, China, where animals were being sold and reported the pattern a full week ahead of the World Health Organization (which reported on Jan. 9) and the U.S. Centers for Disease Control and Prevention (which reported it on Jan. 6).

Dr. Kamran Khan, a professor of medicine and public health at the University of Toronto, founded the company in 2014, in large part after his experience as an infectious disease physician during the 2003 SARS epidemic.

The BlueDot team, which consists largely of doctors and programmers, numbering 40 employees, published their work in the Journal of Travel Medicine.

“Our message is that dangerous outbreaks are increasing in frequency, scale, and impact, and infectious diseases spread fast in our highly interconnected world,” Khan wrote via email. “If we want to get in front of these outbreaks, we are going to have to use the resources available to us — data, analytics, and digital technologies — to literally spread knowledge faster than the diseases spread themselves.”

In the past, BlueDot has been able to predict other patterns of disease spread, such as Zika outbreak in south Florida. Now its list of clients includes the Canadian government and health and security departments around the world. They combine AI with human expertise to monitor risk of disease spread for over 150 different diseases and syndromes globally.

BlueDot, as a company, speaks to the emerging trend of using AI for global health.

In India, for instance, Aindra Systems uses AI to assist in screening for cervical cancer. Globally, one woman dies every two minutes due to cervical cancer, and half a million women are newly diagnosed globally each year: 120,000 of these cases occur in India, where rates are increasing in rural areas.

Founded in 2012 by Adarsh Natarajan, the Aindra team recognized that, in India, mortality rates were high in part due to the six-week delay between collecting samples and reading pathology during cervical cancer screening programs. It was also a human resources issue: in India, one pathologist is expected to serve well over 134,000 Indians.

With the aim of reducing the workload burden and fatigue risk (misdiagnosis rates can increase if the reader is tired and overworked), Aindra built CervAstra. The automated program can stain up to 30 slides at a time and then identify, through an AI program called Clustr, the cells that most appear to be cancerous.

The pathologist then spends time on the flagged samples. Much like traditional global health programs, Aindra works closely with several hospitals and local NGOs in India, and hopes their technology may later be adopted by other developing countries.

“Point of care solutions like CervAstra are relevant to a lot of countries who suffer from forms of cancer but don’t have infrastructure or faculties to deal with it in population based screening programs,” Natarajan says.

Natarajan also points to other areas where AI is relevant in global health, such as drug discovery or assisting specific medical specialists in areas like radiology and pathology. Accenture was able to use AI to identify molecules of interest within 10 months as opposed to the typical timeline of up to 10 years.

The Vector Institute, based in Toronto, is also plugging into the potential of AI and global health. It works as an umbrella for several AI startups, some with a health focus and all aiming to have a global impact.

Melissa Judd, director of academic partnerships at Vector Institute, points to the United Nations’ sustainable development goals as a framework upon which to help orient AI towards improving global health. Lyme disease, for instance, is a global health issue that also comes up against the topic of climate change, and recently a Vector-supported AI initiative was able to identify ticks that spread of Lyme disease in Ontario.

Last December, the Vector Institute launched the Global Health and AI Challenge (GHAI) — a collaboration with the Dalla Lana School of Public Health to engage students from across the University of Toronto (from business to epidemiology to engineering) in critical dialogue and problem solving around a global health challenge.

The potential of AI for global health is immense. Major academic journals are also taking note. Last April the Lancet launched the Artificial Intelligence in Global Health report. By looking at 27 cases of how AI has been used in healthcare, editors proposed a framework to help accelerate the cost-effective use of AI in global health, primarily through collaboration between various stakeholders.

As well, a recent commentary in Science identified several key areas of potential for AI and global health, such as low-cost tools powered by AI (for instance an ultrasound powered through a smartphone) and improving data collection during epidemics.

Yet, the authors caution against seeing AI as a panacea and emphasize that empowering local, country-specific, technology talent will be key, as inequitable redistribution of access to AI technology could worsen the rich-poor divide in global health.

This warning aside, Khan with BlueDot is optimistic.

“We are just beginning to scratch the surface as there are many ways that AI can play a key role in global health. As access to data increases in volume, variety and velocity, we will need analytical tools to make sense of these data. AI can play a really important role in augmenting human intelligence,” Khan says.

**Originally published in CBC News**

Interview Series: Bryant Terry

Interview Series: Bryant Terry

Bryant Terry is a James Beard Award-Winning chef, educator, and author renowned for his activism to create a healthy, just, and sustainable food system. Since 2015 he has been the Chef-in-Residence at the Museum of the African Diaspora (MoAD) in San Francisco where he creates public programming. Alice Waters has remarked, “Bryant Terry knows that good food should be an everyday right and not a privilege.” San Francisco Magazine included Bryant among 11 Smartest People in the Bay Area Food Scene, and Fast Company named him as one of 9 People Who Are Changing the Future of Food. Bryant’s fifth book, Vegetable Kingdom, will be published on February 2020. His last book, Afro-Vegan, was published in 2014 and was named one of the best cookbooks of 2014 by amazon.com and was nominated for an NAACP Award in the Outstanding Literary Work category. Bryant is also the author of the critically acclaimed Vegan Soul Kitchen: Fresh, Healthy, and Creative African-American Cuisine, which was named one of the best vegetarian/vegan cookbooks of the last 25 years by Cooking Light Magazine. www.bryant-terry.com

1. You had an interesting journey before being a food activist What prompted you to begin your work as a food activist?

Years ago, in high school, I first heard the rap song “Beef” by the hip hop group Boogie Down Productions. The lyrics discussed the impact of eating meat on human health, the environment, and animals. That was the first time I realized that I held all of these assumptions about how animals are treated in our food system, and I began eating less meat. I learned a lot about the many reasons to maintain a plant-based diet from lots of older Black vegetarians and vegans. While I was doing doctoral work at NYU in American history I learned about the “Survival Programs” created by the Black Panther Party in the 1960s that addressed the intersection of poverty, malnutrition, and institutional racism—mainly their grocery giveaways and Free breakfast for Children Programs. I realized that historically marginalized communities were still dealing with many of the same problems in regard to food access, so in 2001 I founded a non-profit called b-healthy to raise awareness among young people about the politics of food and give them the tools to improve access to nutritious foods in their communities.

2. How does that inform how you approach healthcare?

I think health ‘care’ system is a misnomer since it often doesn’t refer to caring for people’s health. Mostly we see this medical system responding to illness. I’d like to see a system that is putting more resources into giving patients tools to prevent chronic illnesses and truly “care” for themselves and their families.

3.You had an experience with being challenged with your well-being not that long ago? Can you share more about that?

While working on my last book a few years ago I had lots of time and space to disappear in the writing and recipe testing, which was really exciting. At that time I didn’t have kids and was newly married, and it was all about the hustle. Raising my children and working on my forthcoming book was hard because writing and testing was limited to weekends, holidays, and times when my kids were out of the house. So the struggle of balancing it all felt overwhelming. Things I used to rely on to stay balanced, like my meditation practice, fell away. So now that the book is done I’m preparing to spend the better part of 2020 touring by spending lots of time working on self-care.

4.What does thriving mean to you?

It means different things at different points in life. As a husband with two daughters now, thriving means taking care of my family, preparing my children for the future, and creating space for them to have an enjoyable childhood.

5.What are you most looking forward to in 2020?

I’m very excited about further inspiring people to work towards a more healthy, just, and sustainable food system.

Amitha Kalaichandran: Can we crowdsource a diagnosis?

Amitha Kalaichandran: Can we crowdsource a diagnosis?

Two recent US initiatives: the New York Times’ rare disease column and a TBS series called Chasing the Cure are pointing to an emerging trend in the media: the idea that medicine can crowdsource ideas to diagnose difficult cases. But, can it be used to help diagnose patients, and what are the potential pitfalls?

Reaching a correct diagnosis is the crucial aspect of any consultation, but misdiagnosis is common, with some studies suggesting that medical diagnoses can be wrong, up to 43% according to some studies. This concern was the focus of a recent report by the World Health Organization. Individual doctors may overlook something, draw the wrong conclusion, or have their own cognitive biases which means they make the wrong diagnosis. And while hospital rounds, team meetings, and sharing cases with colleagues are ways in which clinicians try to guard against this, medicine could learn from the tech world by applying the principles of “network analysis” to help solve diagnostic dilemmas.

A recent study in JAMA Network Open applied the principle of collective intelligence to see whether combining physician and medical students’ diagnoses improved accuracy. The research, led by Michael Barnett, of the Harvard Chan School of Public Health, in collaboration with the Human Diagnosis Project, used a large data set from the Human Diagnosis Project to determine the accuracy of diagnosis according to level of training: staff physicians, trainees (residents and fellows), and medical students. First, participants were provided with a structured clinical case and were required to submit their differential diagnosis independently. Then the researchers gathered participants into groups of between two and nine to solve cases collectively.

The researchers found that at an individual level, trainees and staff physicians were similar in their diagnostic accuracy. But even though individual accuracy averaged only about 62.5%, it leaped to as high as 85.6% when doctors solved a diagnostic dilemma as a group. The larger the group, which was capped at nine, the more accurate the diagnosis.

The Human Diagnosis Project now incorporates elements of artificial intelligence, which aims to strengthen the impact of crowdsourcing. Several studies have found that when used appropriately, AI has the potential to improve diagnostic accuracy, particularly in fields like radiology and pathology, and there is emerging evidence when it comes to opthamology.

However, an issue with crowdsourcing and sharing patient data is that it’s unclear how securely patient data are stored and whether patient privacy is protected. This is an issue that comes up time and time again, along with how commercial companies may profit from third parties selling these data, even if presented in aggregate.

As such, while crowdsourcing may help reduce medical diagnostic error, sharing patient information widely, even with a medical group, raises important questions around patient consent and confidentiality.

The second issue involves the patient-physician relationship. So far it doesn’t appear that crowdsourcing has a negative impact in this regard. For instance, in one study over half of patients reported benefit from crowdsourcing difficult conditions, however very few studies have explored this particular issue. It’s entirely possible that patients may want to crowdsource management options for instance, and obtain advice that runs counter to their physicians’ and theoretically this could be a source of tension.

The last issue involves consent. A survey, presented at the Society of General Internal Medicine Annual Meeting in 2015, reported that 80% of patients surveyed consented to crowdsourcing, with 43% preferring verbal consent, and 26% preferring written consent (31% said no consent was needed). Some medico-legal recommendations, however, do outline the potential impact on physicians who crowdsource without the appropriate consent, in addition to the possible liabilities around participating in a crowdsourcing platform when their opinion ends up being incorrect. Clearly these are issues that have no clear answer: and we may end up in a position where patients are eager to crowdsource difficult-to-diagnose (and treat) sets of symptoms, but physicians exercise sensible caution.

It’s often said that medical information doubles every few months, and that time is only shortening. Collectively, there’s an enormous amount of medical knowledge and experience both locally and globally that barely gets tapped into when a new patient reaches our doors in any given hospital or clinic. Applying network intelligence to solving the most challenging, as well as the illusory “easy,” diagnosis, may give patients the best of both worlds: the benefit of their doctor’s empathetic care with the experience and intelligence of a collective many, but the potential downsides deserve attention as well.

**Originally published in the British Medical Journal**

Uncertainty in a Time of Coronavirus

Uncertainty in a Time of Coronavirus

Here’s why communicating public health risk during an epidemic is so challenging

Ann, a friend and mentor in her 50s, exclaimed over coffee at the end of January: “You know, Amazon is sold out of medical masks. You just can’t get any now. But I’m going upstate this weekend, so I should have better luck there.” I looked at her quizzically. At the time, the World Health Organization (WHO) had not yet announced that the newly named disease COVID-19 (formerly known as 2019-nCoV), caused by the virus SARS-CoV-2 (or simply “coronavirus”) was a Public Health Emergency of International Concern (PHEIC), but this announcement was delayed for several days. Besides, masks should only be reserved for people with symptoms.


Ann is an intellectual, someone who doesn’t easily head into panic mode (this helped her in her law career immensely, and later as a CEO and business leader). But in that moment, she had made up her mind: the masks would be a prudent thing to purchase, despite the lack of indication that they were needed. Effectively, Ann was hedging on the idea that, with the messages she received through the media and her friends, it would be better to be more conservative and overly prepared for the worst, given the potential consequences of being underprepared.

It immediately struck me that, despite being trained in both epidemiology and medicine, I wasn’t entirely sure what to advise Ann at the time: the messages I had received, and articles I had read, were no more consistent. There was still much uncertainty around the coronavirus in terms of how serious it was projected to be and what ordinary citizens could do to minimize risk. We all make decisions every day despite uncertainty, and when emotions come into play it can make things trickier.

But when it comes to public health, where the risks of sending the “wrong” message can have devasting consequences—unnecessary anxiety on the one hand (which can take an immense psychological toll) and thousands of unnecessary deaths on the other. To me, one thing is clear: the messaging around coronavirus thus far has been far from ideal, which suggests that uncertainty in a public health emergency is a wrench that can have devastating consequences if it isn’t harnessed appropriately.

Coronavirus is a moving target, as most epidemics are. As a Canadian, I watched with curiosity when Canadian airports decided on January 17 not to screen travelers for coronavirus (the effectiveness of screening is debatable, but the U.S. had already mandated it). But this then changed a mere one day later. The messaging was all over the place: “We thought it wasn’t necessary, but oops, now it might be.” Initially, the WHO wasn’t as concerned: the information and data about coronavirus wasn’t enough to call it an “emergency,” perhaps in part because the institution was reliant on a whole host of assumptions, such as the accuracy of data from China, a country not exactly known for transparency (with some noting the government may have purposely misled the public).

Gradually, the WHO became more concerned, finally on January 30 labelling coronavirus as a PHEIC, which implies a seriousness and a whole other set of other measures should be taken. Now countries as far and wide as Italy, Iran, Korea, and Spain are reporting a high concentration of cases. As of Wednesday, February 26, over 2,700 people had died worldwide from coronavirus since December and over 81,000 were infected globally. To put that in perspective, the SARS epidemic of 2003, which began in November 2002, infected over 8,000 people and led to 774 deaths in a period of six months.

Today the core messages remain unclear. For instance, the WHO has refused to officially advise no travel to China, but the U.S. State Department made this advisory earlier this month. For weeks we also received mixed messaging about human-human transmission, which is now clear, and more disturbingly that it can occur even when someone isn’t symptomatic (though it is rare). Even epidemiologists had trouble deciding how bad it really is. One reason is that a traditional data point in epidemiology, the R0 value, which is the average number of people an infected person is expected to transmit a disease to, is limited in its predictability.

Still, several doctors and public health professionals have taken to social media to remind the world that the flu kills more, as an attempt to dissuade fears, but COVID-19 is more severe, not just in its the ability to send more affected persons into intensive care (like SARS), and that it can kill even young and healthy hosts (as opposed to the more vulnerable who are more affected by the flu), and by most accounts has a higher case fatality rate (the proportion of those with the virus who die), somewhere around 2 percent (though this rate may be lower—0.7 percent—outside of China’s Hubei province) compared to the flu (which has a case fatality rate of around 0.1 percent).

All of this whiplash points to one perhaps uncomfortable thing: no one really knows how bad COVID-19 is, and how much damage it could eventually lead to. We know from postmortems of how SARS and Ebola were approached—both epidemics that provided an opportunity for bodies like the WHO and the Centers for Disease Control to learn from (the CDC provided a report on their Ebola response, and the WHO released a report on outbreak communication immediately after SARS)—that waiting too long to sound the alarm can be disastrous. We also know that the early predictions were based on assuming that China was being transparent and honest about their situational assessment, something we now understand was not the case.

I recently spoke with Kathryn Bertram, of the Johns Hopkins Center for Communication Programs (JHU CCP), who pointed me to the extended parallel process model as a helpful starting point to examine public health messaging during an epidemic. It considers both our rational reactions and emotional reactions (primarily fear) to help determine the best course of action for behavior. On the rational end, we must ask ourselves about “efficacy”—this refers to the effectiveness of a solution (for instance wearing a face mask or avoiding travel to China) and well as our perceptions on how as individuals we can institute this solution effectively. On the emotional end, we ask ourselves about the severity—how severe might it be if we, as individuals were infected, as well as susceptibility (how likely we might contract it).

Herein lies the issue: the perceived threat rests largely on the information we receive from experts. If the threat is high, we make decisions to take protective action. If we are told that the threat is low or even trivial, we are less motivated to protect ourselves even if we have the resources to do so. When an epidemic is underway, uncertainty can create fertile ground for mixed messages and inconsistency, which in itself can breed mistrust and fear.

Reflecting back to my conversation with Ann, I’m reminded of Annie Duke’s book Thinking in Bets, in which she makes a persuasive argument that, as individuals, we’re often required to make decisions based on having incomplete information. Duke uses the analogy of poker, where decisions are made based on an uncertain future. A good decision, despite this uncertainty, rests on whether we use the right process to come to that decision.

As individuals, we also benefit from thinking back to situations where we may have chosen one way but felt if we had a similar choice again we would choose differently, so our memories play a role as well (and arguably for public health we can rely on our collective memory from other coronavirus epidemics, like SARS). She likens our decisions to bets: given the information available to us, along with our memories of how past decisions panned out, and acknowledging that some of the outcome is due to chance, what might be the best choice to make that would most likely provide the most benefit for our future selves?

Bertram underscores the core risk communication principles, which can also be applied to media covering the epidemic: communicate often, communicate what is and isn’t known clearly, and provide simple action items for individuals to take (so things like handwashing).

Similarly, public health stakeholders should communicate what is and isn’t known, coordinate messages to help ensure consistency, and perhaps most importantly, acknowledge that their views (and thus their messaging) may change quickly; thankfully more recently media organizations are choosing to express this uncertainty and a recent op-ed in the New York Times underscores many of these principles, as “people react more rationally and show greater resilience to a full-blown crisis if they are prepared intellectually and emotionally for it.” The authors also urge that we consider using the term “pandemic” (though the WHO is not yet comfortable with this).

Effectively, while the WHO still presents a hopeful view, it and other organizations played poker on a global scale—and the chips they were playing belonged to entire communities. Their decisions and messages matter, and on balance, it might be best to bet that the consequences of underestimating the severity of the pandemic may be worse than overestimating it. The alternative, which brings to mind the dog meme “this is fine,” could lead to both distrust and potentially thousands of unnecessary deaths. It seems that, despite the WHO finally conceding that COVID-19 continues to poses a “grave threat” to the world and may qualify as the long-dreaded “disease X,” the briefing yesterday remained vague and hesitant, and even domestic messaging about whether the virus is contained or spreading continues to be inconsistent. Some have even suggested we finally accept that COVID-19 may be “unstoppable.” Clearly, we’re still down a few chips.


**Originally published in Scientified American, on February 26 2020**