Read the Latest from the Blog!

Yes Please!

Welcome to the Blog

September Newsletter!

September 2021

Welcome to the September issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

 

1. COVID and…
The impact on Pediatric Hospitals in the US:  In Time, veteran health reporter takes us into a busy New Orleans children’s hospital, and the reality that has emerged: Delta is different. Children are not spared. Cases are rising, as are deaths. With vaccine approval pending, stronger mandates may be all we have left.

Vaccine incentives:  Since consulting for Twitter’s health design team, and now serving on their incentives advisory board, I’ve gained a new appreciation for how to incentivize for healthier behavior both online, and offline. Offline, I specifically mean public health behavior. As reported by the CBC, it’s clear that mandating vaccines for social activities like eating at restaurants, is effective in incentivizing those who have held out from being vaccinated. It provides people with a choice: if socializing in private institutions is of value and can supercede any residual mistrust in public health, vaccine rates can increase.

Vaccines — they aren’t a panacea:  In STATNews, an excellent explainer on the COVID19 vaccines, how they work, and the limits.

The brain and mind: From NatGeo, an incredible deep dive into how SARSCoV9 may impact the brain, even or especially in those who had mild respiratory symptoms.

Learning to live with COVID19: echoing the Atlantic, it’s here to stay (and a nice buffer for this poorly titled piece in the same outlet — can we do away with these sorts of forecasts once and for all? Have we not learned to take things one week at a time? 😔). 

2. Podcasts (and shows) worth listening to/watching 
It’s no surprise that most of us are facing trying times mentally and emotionally; this is a time of collective trauma as we face what appears to be a never-ending pandemic. A great podcast with Ezra Klein, interviewing The Body Keeps the Score author Bessel van der Kolk about trauma and the body. Follow this up with Gabby Bernstein’s discussion with the founder of Internal Family Systems Therapy founder, Richard Schwartz. An excellent PDF handout on IFS, as it could apply to *you*, by Canadian psychotherapist, Derek Cook is excellent and found here.

I also had a chance to watch the Susan Sontag documentary, Regarding Susan Sontag, on HBO — what an incredible life! She was a writer who spent time between NYC (West Village) and Paris, bucked the status quo (especially for women) and was insatiably curious. Definitely worth a watch.

3.On…Afghanistan through a renowned author and an inspiring athlete
The situation in Afghanistan is troubling to say the least. This is why both this article, featuring author (and doctor!) Khaled Hosseini in the NYT and another article, also in the NYT, about a ParaOlympian from Afghanistan named Abbas Karimi is timely and inspiring.  

4.Sound (and wise) reflections
~What public health communication can learn from advertising and marketing, in Business Insider. (twitter thread here).
~A powerful essay, in the NYT, about being a full-time caregiver for a loved one during a pandemic

5.Miscellany 
A frightening tragedy in the Bay area, which hit close to home after having recently spent time in SF/Oakland, which included hiking. Thankfully, Pulitzer-prize winning journalist Matthias Gafni, of the SF Chronicle is on the case, hoping the mystery gets solved soon.

I learned a new term in August: “Japandi” — thanks to Better Homes and Gardens. Those who know me know my interest in all things design and design-thinking. For a long time I wondered if Japanese industrial design was more similar to Bauhaus (German) or Scandinavian. Perhaps this answers it, or simply suggests that there’s a different approach that melds it all together. 

Shine Theory came up during a recent Op-Ed Project call. Worth reading (and ideally, integrating!). 

6.Best tweets of the month goes to…

@White_Owly, referencing Oscar Wilde  😜. 

“It is absurd to divide people into good or bad. People are either charming or tedious.”

@Saahil_Desai on diversity in newsrooms — not just reporters but the editors as well (though a quick look at the Atlantic’s masthead suggests it’s not much better  — potentially actually less diverse editorially — than the WaPo) 🙃

“I know we’re all over the Indian Food Discourse, but fundamentally, this is a diversity in journalism problem. If for no other reason, hire nonwhite editors so they help ensure that your publication doesn’t clown itself”

And this clip from Jimmy Fallon/Kit Harrington, because it made me laugh extra hard.

7.Products/Services that have made a meaningful difference during the pandemic:

I’m trying something new this month — this newsletter is not sponsored, but I love sharing products/services (including books, workshops) that have made a meaningful difference in my day-to-day, i.e. things I’d share with my friends. So I thought I’d share one with you each month. This month, I’m sharing the Harmoni standing desk converter. The standing desk craze is a few years old now, and became more popular since work-from-home/WFH began 18 months ago. It’s a good craze overall: sitting for hours on end *isn’t* healthy for us!

That said, I’m a stickler for design, and I try not to buy things that seem too trendy (i.e. what we could get bored of, and what might end up collecting dust), tough to assemble, or bulky and not pleasant design-wise (think lots of metal, plastic etc). So when I heard about the Harmoni desk I knew I found something that would work. It even has a “Japandi” design! A quick search online (amazon, etsy) has a few others that are similar but either require more assembly, are more expensive, or the reviews suggest the wood might be a bit flimsy.

The Harmoni comes in 4 pieces that slot together, which follows the Japanese tradition of “kanawa tsugi,” which means wood joinery via slats. In other words: no tools, nails etc. It takes 15 sec to assemble and disassemble, and stores flat or vertically when you want to use your desk the ‘regular’ way. Best part is that it’s affordable: from approx $250 Cad ($200USD) and up, depending on the finish. Displayed below is the cork mat which I added on to ensure it doesn’t slip. Combine with an anti-fatigue mat to stand on (which you can purchase anywhere), and you have a great WFH setup! 

Again, this isn’t sponsored, so I don’t have a discount code to share, but let me know if you’re using a standing desk or a converter or just improvising (for awhile I just used a lapdesk on top of books). 

In My Own Words…

For STATNews, I wrote about a topic I’ve been a bit obsessed with since December 2020, after an offhand comment a friend made (about being ‘resistant’ to COVID19) caused me to wonder if there were, indeed, people out there that may have true genetic resistance to the virus that has killed millions, crippled economies, and has left the vast majority of us anxious/unwell/uncertain. Indeed, there are — but researchers are only beginning to understand it, and what role this knowledge might play in terms of therapeutics for this pandemic, and others in the future. The response to the article has been great — I continue to receive emails and letters from readers believing they could be resistant (classically: having been exposed to multiple family members, sharing a home, etc but never having a positive antibody or PCR test) and wanting to participate in a North American trial, if the Brazilian trial is replicated. The one question I have left is: now that vaccine rates are high, does this pose issues for discerning who may be resistant?    

I also recently got invited to give a keynote talk at a major conference in November, and now my mind is busy imagining *what* I could talk about and *how* to make the topic compelling. Thankfully, I have time, and will likely build on a recent article I wrote!

A few weeks ago I read the late Susan Sontag’s beautiful New Yorker short story about the time of AIDS, “The Way We Live Now,” published in November 1986. It’s well worth a read as the themes certainly resonate today as well. And, September is National Yoga Month (more information about the evidence here) — try to get out, stretch and move if you can. Earning my yoga teacher training certification in 2016, was one of the best decisions I’ve made, for my body, mind, and spirit.

Have a healthy, joyful, and safe September (and upcoming labor day weekend),


Amitha Kalaichandran, M.D., M.H.S.

When Recovery Requires Rest

By backing away from major sports tournaments, three high profile athletes have prioritized their healing above all else

 

Credit: Rawpixel

Indeed, all three high-ranking athletes have set a precedent for professional athletes to speak up about the need to take a break as part of their healing, placing their mental and physical health above the push to perform. They also offer a chance to revisit the science of why it’s crucial to promote rest for recovery — not just for sports but for all of us.

In 2019, Michael Grandner, a sleep researcher who directors the Sleep and Health Research Program at University of Arizona, found that athletes rated as having clinically moderate to severe insomnia were at a higher concussion risk.

**Originally published in Elemental July 2021**

August Newsletter!

**For photos and access to hyperlinks, please subscribe**

 

August 2021

Welcome to the August issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering this month:
 

1. COVID and…
Delta and Children :  What to be aware of when planning for late summer and Fall.
The CDC reversal “flip flopping” on masks:  And what it means for trust in public health  [and this relates to a piece I wrote for Wired several weeks ago].
On the WHO booster shot moratorium, and imminent pandemic ‘booster shot’ inequality
The role of the media in COVID coverage and public health communication

2. Podcasts (and shows) worth listening to/watching 
A great podcast with Tim Ferris and Michael Pollan on his latest book about plants/plant medicine, and ties to the drug war (including an interesting origin story that harkens back to a never published essay in Harpers).  And one with Ezra Klein in conversation with two giants in understanding the history of race in America, reflecting on the debates around the 1619 Project.

3.On…headaches
A reported Op-ed by Thomas Zellar, on headaches, delves into the realities and research. Complement with the wonderful Joan Didion, whose essay, “In Bed,” is an ode to migraines, and just an excellent model for a science essay.

4.Sound (and wise) reflections
By BF Skinner, on ‘how to discover what to say

5.Miscellany 
~An incredible UCSF study which translated a paralyzed/nonverbal man’s ‘brainwaves’ into words.

6.Best tweets of the month goes to…

Simone Biles, on being more than her occupation. 

“the outpouring [sic] love & support I’ve received has made me realize I’m more than my accomplishments and gymnastics which I never truly believed before.”

Rebecca Carroll, on Issa Rae’s OOO response 🙂

“Issa Rae’s out of office email message says “I am unavailable, unreachable and uninterested for the next two weeks” and I love it.”

and James Clear (who has an excellent Newsletter)

1. Do great work. 2. Share it publicly. 3. Cold email people 2 steps ahead of you. 4. Talk about your work and trade ideas. 5. Host events and meet in-person. 6. Become friends. 7. Rise together.

In My Own Words…

For Elemental, I wrote about recovery and rest, which is more timely now, after the Olympics, as Simone Biles also notoriously stepped away from several gymnastics events (and went on to medal).                     

This has been a trying few weeks, with the emergence of Delta and new lockdowns/restrictions. We’re in a marathon, clearly, which is easier together.

Have a healthy, joyful, and safe August,


Amitha Kalaichandran, M.D., M.H.S.

 

Changing Minds About Why Doctors Change Their Minds

After Covid, being open with patients about uncertainty may be the surest way to build trust in medicine.

IN 2001, when the pediatric allergist Gideon Lack asked a group of some 80 parents in Tel Aviv if their kids were allergic to peanuts, only two or three hands went up. Lack was puzzled. Back home in the UK, peanut allergy had fast become one of the most common allergies among children. When he compared the peanut allergy rates among Israeli children with the rate among Jewish children in the UK, the UK rate was 10 times higher. Was there something in the Israeli environment—a healthier diet, more time in the sun—preventing peanut allergies from developing?

He later realized that many Israeli kids started eating Bamba, a peanut-based snack cookie, as soon as they could handle solid foods. Could early peanut exposure explain it? The idea had never occurred to anyone because it seemed so obviously wrong. For years, pediatricians in the UK, Canada, Australia, and the United States had been telling parents to avoid giving children peanuts until after they’d turned 1, because they thought early exposure could increase the risk of developing an allergy. The American Academy of Pediatrics even included this advice in its infant feeding guidelines.

Lack and his colleagues began planning a randomized clinical trial that would take until 2015 to complete. In the study, published in The New England Journal of Medicine, some children were given peanut protein early in infancy while others waited until after the first year. Children in the first group had an 81 percent lower risk of peanut allergy by age 5. All the past guidelines, developed by expert committees, may have inadvertently contributed to a slow increase in peanut allergies.

As a doctor, I found the results unsettling. Before the findings were released, I had counseled a new parent that her baby girl should avoid allergenic foods such as peanut protein. Looking back, I couldn’t help but feel a twinge of guilt. What if she now had a peanut allergy?

The fact that medical knowledge is always shifting is a challenge for doctors and patients. It can seem as though medical knowledge comes with a disclaimer: “True … for now.”

*

MEDICAL SCHOOL PROFESSORS sometimes joke that half of what students learn will be outdated by the time they graduate. That half often applies to clinical practice guidelines (CPGs), and it has real-life consequences.

A CPG, usually drawn up by expert committees from specialized organizations, exists for almost any ailment with which a patient can be diagnosed. While the guidelines aren’t rules, they are widely referred to and can be cited in medical malpractice cases.

When medical knowledge shifts, guidelines shift. Hormone replacement therapy, for example, used to be the gold-standard treatment for menopausal women struggling with symptoms such as hot flashes and mood changes. Then, in 2013, a trial by the Women’s Health Initiative demonstrated that the therapy may have been riskier than previously thought, and many guidelines were revised.

Also, for many years, women over 40 were urged to get annual mammograms—until new data in 2009 showed that early, routine screenings were resulting in unnecessary biopsies without reducing breast cancer mortality. Regular mammograms are now suggested mainly for women over 50, every other year.

Medical reversals usually happen slowly, after multiple studies shift old recommendations. Covid-19 has accelerated them, and made them both more visible and more unsettling. Early on, even some medical professionals presented the coronavirus as no more severe than the flu, before its true severity was widely described. For a time, people were told not to bother with masks, but then they were advised to try double-masking. Some countries are extending the intervals between the first and second vaccine doses. Of course the state of the pandemic, and of our knowledge about it, has been shifting constantly. Still, throughout the past year and a half, we’ve all experienced medical whiplash.

It’s too early to say how these reversals will affect the way patients perceive the medical profession. On the one hand, seeing debate among medical experts conducted openly could give people a heightened understanding of how medical knowledge evolves. It could also inculcate a lasting skepticism. In 2018, researchers analyzed 50 years’ worth of polling data on trust in medicine. In 1966, 73 percent of Americans reported having confidence in “the leaders of the medical profession.” By 2012 that number had dropped to 34 percent—in part, the authors surmised, because of the continued lack of a universal health care system.

 

*

THE ANCIENT GREEK sea god Proteus was able to see the future, but he was forbidden from sharing his prophecies unless he was captured. This was challenging, because he was a shape-shifter: He could become a young man, a tree, a bull, a flame. No one has explored the protean nature of science more prominently than the Viennese scientist and philosopher Thomas Kuhn. In The Structure of Scientific Revolutions, published in the early 1960s, he proposed that science shape-shifts, or advances, through five sequential phases.

The first involves accepting “normal science,” the prevailing theory or “paradigm,” and conducting experiments that merely verify and reinforce the paradigm. During this phase, skepticism is often suppressed. Phase 2 involves finding an “anomaly” that doesn’t fit with the paradigm, but treating it as an outlier. In phase 3, a critical mass of threatening “anomalies” lead to a “crisis”—which prompts phase 4: “revolution,” by way of a series of new experiments to test alternative theories. Finally, a new worldview emerges, a “mature science.” The phases then repeat.

Remarkably, Kuhn didn’t argue that science is in search of “truth,” but rather that it “moves away from” an outdated, problematic, and “primitive” worldview. Also key is that what scientists and non-scientists understand in the new paradigm is reflective of what they see, as well as what they have been taught to see from experience. A switch in gestalt may be “I used to see a planet, but now I see a satellite”—referring to points in time and assuming that the initial observation may have been true. A paradigm shift, on the other hand, may word it as “I used to see a planet, but I was wrong, as it’s actually a satellite.”

Kuhn based his phases primarily on physics. What happens when we apply them to medicine and health care? When we deal with human lives and preventing illness, “advancement” can look a lot like “flip-flopping.” Is a changed recommendation an admission of harm? And where does that leave us with large public health efforts? Medical reversals place doctors in a bind. Improved medical knowledge represents progress, but honestly admitting to a past error may lead patients to see them as incompetent, breeding mistrust.

 

*

What if we got rid of reversals? That’s what University of Chicago Medical School professor Adam Cifu and oncologist Vinayak Prasad propose in Ending Medical Reversal: Improving Outcomes, Saving Lives. In many cases, they conclude, recommendations are simply issued too soon and are based on low-quality trials. Guideline committees may succumb to groupthink or feel pressured to reach a consensus where none exists. “If we look at something like peanut restriction,” Cifu told me, “the initial recommendations were mostly based on theory—good immunology theory, but theory nonetheless.” If doctors “stick with what’s evidence-based, our advice will be less likely to be overturned.”

Yet diseases don’t wait for evidence. Doctors must sometimes make medical decisions even if good data is rare or unavailable. Cifu and Prasad draw a sharp distinction between evidence- and theory-based recommendations, but in practice, doctors often adopt a looser framework. They may use lower-quality (often theory-based) recommendations until they can be replaced with higher-quality ones. Doctors combine this knowledge with their own personal experience in making clinical decisions.

Medical guidelines are similarly a composite thing, often seeking to balance new evidence with deference to established authority. And decisionmakers may also consider how a revision will affect trust in the system as a whole. In the 1990s, for example, the rotavirus gastroenteritis infection killed more than 130,000 children globally each year. In 1998 the pharmaceutical company Wyeth released a vaccine, called RotaShield, that dramatically reduced the mortality rate. Within a year, however, doctors and patients poured in with complaints. Among the inoculated, there seemed to be a small increase in a bowel condition called intussusception, which in rare cases can be deadly. In 1999, after 15 reported cases of vaccine-related intussusception, both the Vaccine Adverse Event Reporting System (VAERS) and the Centers for Disease Control ordered that RotaShield be withdrawn from the American market. It’s worth noting that VAERS is limited by the honor code: Adverse events are not confirmed.

*

In a 2012 paper titled “The First Rotavirus Vaccine and the Politics of Acceptable Risk,” Jason Schwartz, then a fellow at the University of Pennsylvania, explored the thinking behind the withdrawal. In his view, the decision wasn’t purely evidence-based. Schwartz told me that while some “argued that keeping the vaccine would have, in absolute terms, saved more lives,” the decisionmakers weighed trust: “You can’t have a vaccine out there with a notable risk of a harmful condition.”

According to this reasoning, the RotaShield reversal should increase our trust in vaccines: It shows that the system we use to monitor them works. (Two safer rotavirus vaccines have since been introduced and remain in use.) Vaccines such as MMR have been monitored for decades by the same system, and observers have seen no alarming signs—proof of their extraordinary safety. We’ve recently seen similar safety processes play out with the AstraZeneca and Johnson & Johnson Covid-19 vaccines. Still, a paradox of medicine is that the steps we take to make the system more trustworthy can make it seem less so.

THE FLIP SIDE of that paradox is that getting doctors to be comfortable expressing uncertainty may be the surest way to instill patient trust. Steven Hatch, a professor of infectious diseases at the University of Massachusetts, argues that medical reversals unsettle us because both medical professionals and patients are too fixated on being sure. “The public often thinks that they go to their doctor, the doctor runs the test, and the test reveals the truth,” Hatch told me. “But most of the time, we weigh sets of data and arrive at weighted possibilities which are not rock-solid.”

Doctors might approach different kinds of patients differently. Some people are comfortable with uncertainty and risk; others, says Hatch, struggle “to deal with ambiguity in their lives in general.” With the latter, doctors must resist the temptation to create a false sense of certainty, because “it’s really when things go wrong that a patient may feel cheated by the system.”

Hatch’s observations made me think of Diane, a woman I met a few years ago at a yoga retreat. Now in her sixties and retired, Diane is healthy, active, and cheerful, but she’d gone decades without visiting a doctor. She’d avoided preventative screenings of all kinds, in large part because it seemed to her that medical advice is always changing.

A few years ago, one of Diane’s friends—a woman who’d also avoided routine screenings—died of colon cancer. This inspired Diane to make a few doctor’s appointments and, in December 2019, she had her first physical exam since the early 1990s. Still, she found herself confused about how much uncertainty was normal in the doctor-patient relationship. She told me that when she asked her doctor if a prescribed skin cream would make her skin sensitive to the sun, her doctor told Diane that sun sensitivity wasn’t a side effect. Later, at home, Diane looked up the medication and found a warning that the cream actually did make people more sensitive to sunlight. “The doctor admitted to being unsure, which didn’t bother me,” Diane said. “But then she ended up telling me the wrong information. It’s hard for me to overlook that.”

Diane has struggled with the changing recommendations during the pandemic, and with figuring out how they should shape her behavior. “It almost seems like no one knew what they were talking about,” she recently told me. “First, it was no mask, then it was mask. Now, it’s two masks. It’s hard to keep up.”

Diane’s husband is a pilot, so I suggested a flying analogy. Sometimes a pilot who has been flying the same route for years has to shift because of severe turbulence or weather, perhaps flying thousands of feet higher or lower than what was originally planned. Usually the pilot announces the change to the cabin, and the passengers understand. Most don’t see the pilot as newly untrustworthy or incompetent; on the contrary, they’d worry if the plane shifted course and no announcement was made. Changes are inevitable when new information arrives, and transparency should increase trust, not erode it.

 

The Re-Emergence Effect

It will take time and patience to reemerge from the collective crisis of the pandemic with our mental and physical health intact.

When I met Darren Sudman six years ago, at an event in Palm Springs, I didn’t expect that his story would be one that I would return to time and again as I began examining what makes us thrive and heal after difficult times.

Sudman introduced himself as a former lawyer and a founder of a nonprofit. In 2004, Sudman and his wife, Phyllis, experienced every parent’s worst nightmare: Their three-month-old son, Simon, was found motionless in his crib. He had passed away from sudden infant death syndrome (SIDS), later deemed to be secondary to a heart rhythm disturbance called “long QT syndrome.”

Sudman’s nonprofit, Simon’s Heart, was created with the purpose of screening children early in life. It has kept us in touch over the years. But it was what Sudman shared about how he emerged from this unspeakable tragedy, and was able to move forward, that has continued to stay with me — particularly during this time as I reflect on our collective reemergence after the pandemic.

“My daughter was two and she needed me to get out of bed every day. She was really young and didn’t have a grasp of what was going on, and I had to take care of her. That forced me to wake up and live every day as best I could — she was my motivation,” Sudman told me. He also shared advice his co-worker provided at the time: “‘When you feel grief, let it pull you under and don’t resist it — it’s temporary and when you’re ready, you’ll come back up.’ This idea continues to work for me.”

In March 2021, a survey from the American Psychological Association found that 49% of adults reported feeling uncomfortable about returning to in-person interactions when the pandemic ends, and this included those who were vaccinated.

In China, after lockdowns lifted and people reemerged, over 10% met diagnostic criteria for post-traumatic stress disorder (PTSD). Indeed, for roughly 14 months most of us adjusted to a modified sense of “normal,” in much the same way a person living in a cave for a year may adjust to the lack of cognitive and light stimulation.

Change — even if it comes in the form of freedom — is still uncomfortable. So, it’s no surprise that some doctors are admitting to their own reemergence anxiety, that this summer terrifies a lot of people (perhaps especially introverts), and that many are worried about returning to work. Things will get better and the pandemic as it stands will end and Covid is most likely transforming into an endemic seasonal virus, yet all signs are clear that we must prepare for a reemergence effect.

Javeed Sukhera, chief of psychiatry at Hartford Hospital in Connecticut, shared that the reemergence process may feel similar to grief. “Especially for those who struggle with tolerance for ambiguity and when circumstances are not in their control,” Sukhera shared, “They will either adapt to the stressor and reflect more on the meaning of things, or risk of falling back into maladaptive ways of coping.”

*

Reemergence effects are not new.

We can look at butterflies as an example from nature — a caterpillar spends up to two weeks in a cocoon dissolving into a stew of cells, which it then partially ingests before swiftly emerging as one of our most prized insects.

I think back to a training in humanitarian emergencies I took at Harvard several years ago. The crisis situations were almost always in developing countries, where we needed to sort out food, water, and safety (for instance, from civil war and infectious diseases). A core part of our training was how to reemerge from the crisis with our mental and physical health intact. This involved time and connecting to resources to integrate back into the societies we had left — lessons I took to heart and applied during research or clinical work in low resource settings.

There are also examples from history.

Some Holocaust survivors, once freed from Auschwitz, marched across the camp and to freedom, but promptly returned: Writer and psychologist Edith Eger suggested, “They didn’t know what to do with their freedom,” and a return to life was challenging.

We see this in medicine as well.

compelling case of a man who spent decades legally blind had his eyesight restored only to suffer a psychological breakdown as he reemerged with the vision he had become accustomed to not having. The criminal justice system is also illustrative: The recent release of Joe Ligon, who spent 68 years of his life incarcerated, suggests that his true sense of freedom may be linked to how well he is supported during his reintegration into society. Indeed, once we start looking, we see “reemergence effects” everywhere — moments when, after spending a length of time in one state and having adjusted, we are forced to shift to another. Even if our new state is objectively better, our minds are still impacted.

Rachel Yehuda, a professor of psychiatry at Mount Sinai who specializes in trauma, expected many would seek therapy during Covid, the numbers were not as high as expected, which suggests to her that there may be an immense need after the crisis as part of our reemergence.

Joy Harden Bradford, an Atlanta-based clinical psychologist, agrees. “Many people may experience a post-traumatic stress response several months after we emerge that may take them by surprise as they may be getting through this difficult time by not fully acknowledging and processing what’s been happening, likely because it was their only way to keep functioning,” Bradford said.

As such, part of planning for our reemergence will involve anticipating our future mental health needs. Reconstruction after a humanitarian crisis is common, and often provides an opportunity for mental health reform; this was echoed in a UN report published last year. The idea of “building back better” for children’s mental health is instructive and could apply more widely.

“If I had a magic wand, in terms of building unlimited capacity for healing, I would initiate a campaign called ‘Let’s Talk About it,’ meaning, talk about the challenges, and the pain, and how we felt at the time. And it wouldn’t necessarily have to be with a mental health provider,” Yehuda told me. “Ideally, we would come together with people we know in our communities, in places of worship, the gym, yoga studio, or book club and ask each other, ‘What was it like for you?’”

And we may very well emerge better in some ways, perhaps a bit surprised by our own resilience, a point Yehuda wants to underscore.

“Time does heal, and the desire to flex our resilience muscles is powerful. That most of us will recover is an important public health message,” she shared.

*

With butterflies, it turns out that my understanding of their reemergence was incorrect. There’s more to the process. When a butterfly emerges from the cocoon it’s still a goopy wet mess. Its wings are too small to fly. To expand them, it must actively pump in fluid from its abdomen — a bit like blowing up a balloon. Then its wings must dry under the sun. And then — as anyone who has spent a prolonged length of time in a hospital bed, and experienced muscular deconditioning, knows well — the butterfly must exercise its fragile wing muscles enough to ensure they stay up against gravity in order to fly.

In other words, a butterfly’s reemergence isn’t swift at all: it takes intention, time, and effort.

Our collective reemergence may be similar. It must be handled with care, patience, and ideally capacity to receive our mental health needs on the other side of this pandemic. Engaging in a collective reenvisioning both around what capacities should be built now, in preparation for that reemergence is part of our collective post-traumatic growth, and goes beyond resilience to involve creating of meaning from crises, which could perhaps buffer some of the harmful elements of the reemergence effect.

Though I didn’t appreciate it six years ago, this was perhaps the biggest lesson I learned from Darren Sudman, which I hope we can all put into practice today as we reemerge stronger and more whole. Sudman’s intentional efforts to steer his family’s crisis into one that could help other parents helped offset his personal horror of reemerging as a parent who had lost a child.

“We had just suffered one of the worst tragedies but through it we [created] new narratives that involve helping prevent this from happening to other children, meeting families with similar experiences. When Jaden, our third child, came home, he brought another ray of sunshine to our house and reinforced the fact that life goes on and there’s still goodness.”

**Originally published in Elemental in May 2021**

Can Prayer Heal?

Does spirituality play a role in health outcomes?

Credit: RawPixel

On the last day of January, my Twitter feed lit up with a curious and heartfelt call: “Please. Please. Please. Everyone PRAY for my daughter Molly. She has been in an accident and suffered a brain trauma. She’s unconscious in the ICU. Please RT and PRAY.”

The tweet came from a woman named Kaye, a lawyer and mother of three in Los Angeles. Her daughter Molly was in a pediatric intensive care unit after suffering a brain injury. I, along with thousands of others, heeded her call, sharing a private prayer that Molly would recover. Soon Kaye began tweeting live as to Molly’s status — she regressed with brain swelling, needing surgical intervention. She was then stable for another day before her blood pressure and the pressure in her brain (intracranial pressure) fluctuated, needing another brain scan and another surgery to reduce the intracranial pressure.

By sharing what was happening for Molly, Kaye brought thousands of us into that small ICU room over several days, highlighting the hard work and efforts by Molly’s doctors and requesting that followers (the number amassed to more than 60,000 within the span of just a few days) do one thing: pray.

The research on intercessory prayer—the formal name for praying to a higher being or force, for ourselves or for others—paints a conflicting picture. In 2020, a published case report caught my eye: A patient’s blindness “resolved” after the patient received intercessory prayer. But the case happened in 1972; surely the details may have become muddled in the retelling over several decades. The same researchers reported on other cases, like prayer for gastroparesis (when the stomach becomes unable to function) in a 16-year-old. Other research suggests prayer may be helpful as an adjunct for pain management among patients who might describe themselves as religious.

In 2006, researchers from the Mind-Body Medical Institute at Harvard Medical School reported on the Study of the Therapeutic Effects of Intercessory Prayer (STEP). This trial involved cardiac bypass patients across six hospitals in the United States. Each participant was in one of three groups: One-third received prayer from others after not being told if they would or not, another third didn’t receive prayer after being told they may or may not receive it, and the last third were told they would receive prayer. In the end there was no significant difference in death rates (mortality) between the groups.

Perhaps most prominently, a Cochrane review from 2009 that reviewed 10 studies and more than 7,500 participants compared intercessory prayer plus standard care with standard care alone and found that the results were equivocal — in other words, prayer didn’t make a difference to the patient’s outcome. That review was then criticized as failing to “live up to the high standards required of Cochrane reviews,” and other researchers have criticized the study more generally.

Yet, spirituality may effectively be a way to create meaning out of the experience. It can also help patients create meaning from their experiences.

Jonah Geffen, a 44-year-old rabbi in Manhattan, echoed some of these same sentiments. His path into spiritual work involved a stint at law school, after earning a master’s in conflict analysis and resolution. Now he works primarily in the community but on occasion gets called into hospitals or people’s homes specifically for healing purposes.

“[As a] rabbi… generally, no matter where you are, what you’re doing, there’s always an element of care involved in it… very often someone looking to heal something,” Geffen told me.

Over the years, Geffen has become prepared to run to someone’s side in the hospital or at home when crisis hits. He adds that the biggest challenge he sees, among those who are chaplains in hospitals, is that much of the time they might be asked to pray for someone outside their faith.

“It’s a challenge with some of the rabbis I know who might be asked to pray for someone. In our tradition, prayers are quite scripted, so the challenge is for them to step out of that and find another way to connect with that person and to God,” he says.

Christina Puchalski, MD, a physician based in Washington, D.C., became interested in spirituality at an early age. “There wasn’t one specific thing that got me interested in orienting myself towards the spiritual needs of my patients. I suppose it was years of knowing my connection to the sacred and that so much of the suffering we see in our patients is of the spiritual kind,” Puchalski told me.

In 1996, Puchalski developed the FICA (faith/belief/meaning; importance/influence; community; address/action of care) spiritual assessment tool for health professionals to help them integrate spiritual views into a patient’s clinical history. Puchalski has worked with everyone from the Vatican to the World Health Organization (WHO). With the WHO, she has advocated to include “spirit” within the definition of health, specifically in the realm of palliative care.

Currently, Puchalski leads the George Washington Institute for Spirituality and Health, dubbed GWish. Established in 2001, the institute has the primary role of raising awareness about the spiritual aspect of patient well-being. It’s the biggest center of its kind in the United States.

In her book Making Health Care Whole, Puchalski defines spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” She goes on to emphasize that spirituality helps us find meaning and purpose “even in the midst of failed jobs, relationships, accomplishments, and unattained successes, especially at the end of life… The inability to find meaning and purpose can lead to depression and anxiety.”

According to Puchalski, the triggers for potential spiritual growth can include serious illness, aging, loss of a loved one, stress, life change, social events, and tragedies.

So perhaps what Geffen and Puchalski are both alluding to is that asking whether prayer “works”—as in whether it hastens recovery—is not the right question, even if it’s important from a research and evidence-based point of view. Instead, perhaps it’s important to define the outcome more holistically: as a measure of healing for both the patient and their family, one that transcends merely “curing” or “recovery.” As well, perhaps the word “prayer” is unnecessarily constraining. We could instead reframe it as “compassionate and caring presence” for another person, where we genuinely hold their well-being in our thoughts.

On February 15, Kaye shared an update that Molly had passed away and that her family was grateful that the request for prayer, regardless of one’s faith, was heard and met many times over in the form of an outpouring of compassion from a community of friends and strangers. She said it brought comfort and a sense of being witnessed during the family’s time of immense need. Perhaps this same sort of compassionate presence has the potential to heal and assist those suffering with an unimaginable reality and subsequent uncertainty, even if, in the end, we’re met with the limits medicine itself places on the ability to cure.

**Originally published in Elemental, March 2021**

June/July Newsletter!

 

June/July 2021

Welcome to the June/July issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

A forest playground, near Chattahoochee Hills, Georgia, May 2021

Some things that had me wondering this month:

1. COVID and…
Pediatric Multinflammatory multisystem syndrome:  In the Lancet, some good news: the sequelae (long lasting effects) of the initial symptoms may not persist past 6 months.

On masks:  When and where to wear them, by a pubic health expert, in Slate and…could they be here to stay for cold/flu season (I think so), in the New York Times.

Vaccine Hesitancy: Among healthcare workers in the New York Times.

and….

How the pandemic ends, by the indomitable Helen Branswell, in STATNews.

2. Podcasts (and shows) worth listening to/watching 
The best series I’ve watched in a long time is “The Me you Can’t See,” a series on mental health and wellbeing, produced by Oprah and Prince Harry. I especially loved the last episode, which placed a solutions-lens on mental health as well where this issue intersects with other contemporary challenges, such as policing. Make the time to watch!

3.On…reconciling with Canada’s challenging past with residential schools
In the CBC, the discovery of the bodies of 215 Indigenous children, some as young as three, rippled throughout the country. It’s likely there are many similar mass graves across the nation. First comes ‘truth’ and understanding the true scope of this tragic legacy, and then reconciliation. I sense that we’re only beginning to get to the truth bit.

4.Sound (and wise) reflections
~In NiemanLab, why Darnella Frazier, now 18, should win a Pulitzer for her bravery in capturing the tragic death of George Floyd, which had a ripple effect on how we understand systemic racism in policing and more broadly in our society.
~Billy Porter, on sharing his truth as a man living with HIV, in the Hollywood Reporter
~On the Cicadas who are re-emerging after years, in the New York Times.

5.Miscellany 
~I developed a tree pollen allergy last year, and have been sneezing nonstop seemingly this month. Finally, I have my answer, from CTV.

~On brain implants that could translate thoughts into text, in Wired

~For subscribers to STAT+, the investment in healthcare teams, by tech companies.

~From Yahoo, the tragic death of Michael Lewis’ daughter, Dixie (along with her boyfriend, Ross Schultz), in a car accident last week reverberated throughout the literary community. Lewis is one of the most talented narrative nonfiction writers, and I just started his latest: The Premonition, about the pandemic. His podcast, with Pushkin Industries, Against the Rules, is one of my favorites, and last season he described being coached for singing, drawing parallels with Dixie’s experience with her softball coach. May Dixie and Ross rest in peace. 

6.Best tweets of the month goes to…

Adam Grant, on a mantra we need to finally do away with:

“We’ve always done it that way” is not a valid reason for anything. Don’t follow traditions because the status quo is comfortable and change makes you uncomfortable. Question whether past routines are serving you well in the present and guiding you toward a better future.

Rebecca Herbert, on attachment (or…”inosculation”, in the plant world) which continues to be a theme I think about often: 

The thinner tree was cut years ago and the big one has been holding and feeding it since then. They “wake up” together in the spring and “go to sleep” together in the autumn.

An excellent thread by Marie Beecham on cancel culture as a form of intellectualism.

This sums up a lot of the past 18 months with the pandemic: Mike DiCenzo: (a former writer for Jimmy Fallon, the Onion, etc):

Nobody really knows anything. Everyone’s just saying things. But some people say things more confidently than others.


NYC, enlivened, as the storm clouds (of COVID) appears to be clearing! May 2021 

 

In My Own Words…

For Elemental, I wrote about the “re-emergence” effect we may all be experiencing. And for Wired, I wrote about medical reversals, and what they mean in the broader context of our post-COVID world.

This was also a month with additional ‘in person’ reporting in and around New York with sources I couldn’t meet in person a year ago, given the lockdowns. We also cemented the title (On Healing will be the final!) and the subtitle (this was a toss up between two — so stay tuned!) and hopefully I’ll be able to share the cover in the next newsletter.

And a brand new book to be sure to get your hands on, by my friend Barrett Swanson (I’ve linked to his essays in previous newsletter): Lost in Summerland. This interview, in LitHub, is a great as well.

Have a healthy, joyful, and safe June and July!


Amitha Kalaichandran, M.D., M.H.S.

We Must Rethink the Role of Medical Expert Witnesses

The Derek Chauvin trial highlighted a potential way physicians could better serve the criminal justice system

Credit: Getty Images

In the aftermath of the guilty verdict in the trial of Minnesota police officer Derek Chauvin for the murder of George Floyd, a consistent element of many criminal trials came into sharp focus: the role of medical expert witnesses, and the influence they wield in the courtroom, particularly as it relates to determining the cause of death. Within the span of the ensuing weeks, one juror said that the medical expert testimony was particularly influential, and a petition to investigate another medical expert witness’s track record of assessing cases for potential bias, garnered over 400 signatures from concerned physicians. Clearly, it’s worth asking this question: If the broader goal is to improve justice, can the system of using medical expert witnesses be re-imagined? This question can be examined by highlighting three main challenges.

First, the term “expert” is tricky in medicine, as medical science evolves rapidly (COVID is a prime example). Yesterday’s expert could be out of touch with their field of expertise today. Further, the prosecution and defense choose the expert most appropriate for supporting their respective legal strategies, which runs the risk of confirmation bias. At its best, medicine is a group sport; in hospitals, particularly for challenging cases, physicians share their knowledge; debate and discuss a case; and formulate plans in consultation with each other. And when it comes to the determination of death, the standard for group involvement is often higher. For brain death, for instance, two different physicians’ assessments may improve the likelihood of an accurate assessment.

The second issue is that the standard used by the courts to assess whether an expert witness’s scientific testimony can be included differs by state. Several states (including Minnesota) use the Frye Rule, established in 1923, which asks whether the expert’s assessment is generally accepted by the scientific community that specializes in this narrow field of expertise. Federally, and in several other states, the Daubert Standard of 1993 is used, which dictates the expert show their scientific reasoning (so the determination of validity is left to the courts), though acceptance within the scientific community is still a factor. Each standard has its drawbacks. For instance, in Frye, the expert’s community could be narrowly drawn by the legal team in a way that helps bolster the expert’s outdated or rare perspective, and the Daubert standard presumes that the judge and jury have an understanding of the science in order to independently assess scientific validity. Some states also strictly apply the standard, whereas others are more flexible. (The Canadian approach is derived from the case R v. Mohan, which states the expert be qualified and their testimony be relevant, but the test for “reliability” is left to the courts).

Third, when it comes to assessments of cause of death specifically, understanding the distinction between necessary and sufficient is important. Juries can have a hard time teasing out the difference. In the Chauvin trial, the medical expert witnesses testifying on behalf of the prosecution were aligned in their assessment of what killed Floyd: the sustained pressure of the officer’s knee on Floyd’s neck (note that asphyxia is a common cause of cardiac arrest). However, David Fowler, the medical expert witness for the defense, suggested the asphyxia was secondary to heart disease and drug intoxication as meaningful contributors to his death.

An example of a cause being sufficient on its own might be a person who is pushed out of a plane, at 10,000 feet without a parachute. In a case like that, having a preexisting condition is inconsequential to their certain death. An example of a cause being necessary but not sufficient might be an individual with a compromised immune system who is infected with the influenza virus; neither condition alone would typically be lethal, but the combination might well be. With the Chauvin case, the disagreement between the medical expert witnesses was effectively over whether the force used was sufficient to cause Floyd’s death, irrespective of preexisting conditions (akin to the example of being dropped out of a plane) or whether it was only deadly in combination with another condition such as trace amounts of drugs (i.e., more similar to a person with preexisting conditions dying from influenza).

If we had the opportunity to re-imagine how medical expert witnesses might be used more effectively, how would we approach it?

In a 2010 Canadian paper, two scholars made several recommendations, including that these experts share only opinions (based on facts and reasoning, ideally supported by the medical literature) from their area of expertise, make clear where elements may be controversial in the scientific community, avoid confusing jargon during their testimony, and be informed that their primary role is to assist the court by providing testimony that is impartial, as in free from bias.

Arguments to improve how medical expert witnesses serve the justice system have been made by prominent legal scholars such as David Faigman, the Chancellor and Dean and John F Digardi Distinguished Professor of Law at the University of California Hastings School of Law. However, Faigman shared that it remains a challenge to convince the courts to re-imagine this system.

One potential improvement involves vetting medical expert witnesses for potential biases, such as those based on gender or race before they take the stand (Fowler, the medical expert on Chauvin’s defense team, was involved in another similar case, involving the death of a young Black man, which raised concerns, which is leading to a review of his other cases after an open letter signed by over 400 physicians). According to Faigman, currently only good cross-examination may help elucidate these biases during a trial. As well, biases related to compensation could potentially be avoided by instituting a common pool of funding, with a standard rate, though in practice, this would be challenging to put in place.

Another improvement could involve ensuring that courts institute a more stringent application and selection process, in which medical expert witnesses would be required to demonstrate their clinical and research competence related to the specific issues in a case, and where their abilities are recognized by their professional group. For example, the American College of Cardiology could endorse a cardiologist as a leader in a relevant subspecialty—a similar approach has been suggested as a way to reform medical expert witness testimony by emergency physicians. One drawback, according to Faigman, is that courts would be unlikely to fully abdicate their role in evaluating expertise.

Last, instead of medical experts working for both sides, the courts could appoint a panel of medical experts who are required to explain their assessments (which would be part of the record) independently of each other and the opposing legal teams, but also have the panel work together and deliberate on a final assessment. Faigman shared that while this would offer an ideal solution, the courts would still need to decide how best to appoint and compensate this panel.

In any case, borrowing from how medicine works at its best in hospitals, to improve the current model in court may help us better reach our common goal of justice.

Since the time of Chiron, doctors have been viewed as godlike. More recently, and particularly during the pandemic, we realize that physicians have limits to their knowledge. Perhaps no other physician described the fallibility of doctors more profoundly than Roger I. Lee, who served as the president of the American Medical Association. In an essay aptly titled “Are Doctors People?” published in the New England Journal of Medicine in 1944, he wrote:

“We must accept the fact that the community, from the days of folklore and the

medicine man to the present, conceives the medicine man and the doctor as someone apart

from the rest of the tribe or the rest of the community…[but] Doctors are human beings.”

Lee was ahead of his time in his recognition that doctors also have a role to play in ameliorating social ills. Systemic racism is perhaps the most profound of these ills. The Chauvin trial has only furthered the salience and limits of physician expertise and judgement in the criminal justice system. While the verdict was ultimately aligned with the majority of medical expert witnesses, and those physicians who assessed Floyd at the time, it’s on us to make the system better.

**Originally published in Scientific American, May 2021**

May newsletter!

May 2021

Welcome to the May issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering this month:

1. COVID and…
India:  The situation in India is devastating, to say the least. I’ve written about the role of large companies in helping us address the pandemic in North America (I wrote about some ideas in Fast Company last March, and for Medium). After an initial block on raw materials, the US lifted the ban, which was wonderful news. Companies like Salesforce and Apple have also stepped up to help, and the diaspora has spoken out as well (Toronto Star)

Brazil: The plight of COVID children was meticulously described in NBC News — what might explain this pattern in Brazil, but not North America?  And, in the Globe and Mail, the tragic story of Emily Victoria Viegas, a 13 year old who died In Brampton Ontario

Vaccine Hesitancy: Some ideas on how to re-think it, in the New York Times. Two years ago I tackled the challenge more generally in the LATimes — it’s not about knowledge as much as it’s about understanding, the influence of our peers/social network, and our personal experiences intersecting with our values.

The Color Line: I’ve been waiting for someone to take a deep dive into the disproportionate element of race during this pandemic. Ibram Kendi did just that, in The Atlantic, and it’s worth a read.

To Mask or Not to Mask (and risks):  Nikole Hannah Jones’ Tweet suggests that masking may be a social good in more ways than one. For the Globe and Mail, Andre Picard places the salience of risk assessment, as it relates to the vaccines, in perspective.

Organized Chaos: In Canada, a big batch of vaccines from Johnson and Johnson was held back for inspection (note they arrived from the same US factory that was problematic), the National Advisory Council on Immunizations provided mixed messaging regarding two tiers of vaccines, meanwhile the US is looking to expand vaccine eligibility for the Pfizer vaccine to 12-15 year olds (though herd immunity is looking more unlikely).  That said, the W.H.O. had *finally* deemed COVID airborne (GREAT news) just weeks after an urgent an op-ed by the head of the W.H.O. that was timely and important.

2. Podcasts to listen to:
On her Dare to Lead Podcast, Brene Brown’s interview with Michael Bungay Stanier was brilliant. One big take-home (and there were many) was how to handle requests for giving advice, in a way that places the onus on the asker. It made me think a *lot* about  motivational interviewing: the aim being to help clarify the person’s goals, and reminding them of their own agency. Another interview, on the same podcast, with Angela Duckworth was also a worthwhile listen, especially near the end, when both Brown and Duckworth share experiences with envy and how best to channel that sentiment productively.

This Tim Ferris podcast episode, with Balaji Srinivasan, was from the end of March, but I listened to it in early April (late to the party). It’s well worth the 3.5 hour listen (in chunks!). Some highlights: how autonomy can help offset cancel culture, the future of cryptocurrency, and what work/purpose may eventually look like for each of us. I also appreciated Srinivasan’s orientation towards legacy building, and ‘giving back’ after his success.  

While not a podcast, an incredible Audiobook to make time for is: What Happened to You, by Oprah and Bruce Perry (a psychiatrist) which takes a deep dive into trauma. Over the last year I’ve realized how much is secondary to trauma — how we respond to things and how others respond for instance. These traumatic events, as Gabor Mate shared during a chat earlier this year, can seem minor at the time but they all lead to patterns that underlie how we understand the world and how we interact with others and respond to others. It has deepened my understanding of others and myself. The book wraps up with Oprah doubling down on post-traumatic ‘wisdom’ with some words around making ‘trauma your power.’  

3.On…re-examining medical culture (from 2017)
In the American Academy of Family Physicians — a nice framework for shifting medical culture, both as a leader and someone who is being ‘led.’ 

4.Sound (and wise) reflections
~On languishing, by Adam Grant in the NYT (who humbly shared a counterpoint by Austin Kleon)
~Newark police reform seems to have worked, in NJ.com. 
~Why the dental ‘system’ is so broken, in Canada at least, via The Walrus. It’s a great title too.

5.Miscellany 
~From STATNews: while diversity and inclusion efforts have expanded in most industries, medical education/medical schools is not one. And, in Time, how medical journals remain resistant to writing about systemic racism
~Cancel culture x Shame, by Ezra Klein in the NYT. I’d love to see/hear Brene Brown’s take on this topic.
~The history of the Rubik’s cube — I’ll have more to share in due time (it’s briefly in my book)! 

6.Best tweets of the month goes to…

Via Tim Ferris:
“Let me never fall into the vulgar mistake of dreaming that I am persecuted whenever I am contradicted.” — Ralph Waldo Emerson

By @ProductHunt — your brain on Zoom (without breaks)

A lovely cartoon by one of my favorite children’s book illustrators, Debbie Ridpath Ohi on ignoring writing competition, and focusing on your own journey and pace

Viral viral thread on imaginary New Yorker covers — this one made me cry (a perfect depiction of grief).

And by @JamaalBowmanNY
Addiction requires love — not jail.

And last: @EzraKlein, on anxiety

And then came the pandemic. Reality was objectively terrifying, and many of us were trapped inside, severed from social connection and routine, with acres of time to fret. It was a bad mix. I know a lot of people who didn’t have an anxiety problem before, but do now.


In My Own Words…

For the last year, I’ve been perplexed by the role of medical expert witnesses in the criminal justice system. I didn’t have a reason to explore it until the Chauvin/George Floyd trial, and came across an excellent law review paper by David Faigman (Chancellor of UC Hastings School of Law) which got me thinking. It was truly a page turner!! 
I shared my thoughts in an opinion/analysis piece for Scientific American here.

This was a month with lots of *editing* of my first book draft; I completed the second draft in early May. One of the best books I’ve read over the last few months was by Ashley Bristowe, My Own Blood, which explores how, as a mother of a child with a rare health condition, she was able to navigate both the medical world and the personal world. I highly recommend it — we rarely get insight into these struggles from the ‘patient’ side of things.

It’s promising to see that in some places–parts of the US, things are opening up and vaccine rates are high. Canada still has issues with the vaccine supply, and places like India do as well. I had COVID last year and tested positive for antibodies before receiving the first dose of Pfizer — surprisingly I didn’t become ill but will have to see what the second shot will show. I’m feeling more optimistic than I have in over a year that things will start to open up in the Fall in most places in North America. Hopefully the whole world will be in a position to see the end of this terrible pandemic very soon as well — there’s no ‘them,’ just us, and if there was ever a time for vaccine diplomacy and general regard for global health, this is it.

Have a healthy, joyful, and safe month,


Amitha Kalaichandran, M.D., M.H.S.

Actually, Covid Optimists and Pessimists Are Both Right

Mild and dire forecasting models serve different purposes, and can be tricky to interpret. But when they appear similar, it may signal the end of the pandemic.

 

c/o Getty Images

CONSIDER THIS THOUGHT experiment: J is a 55 year-old patient who has smoked two packs of cigarettes a day since he was 22. He has just been diagnosed with stage III non-small-cell lung cancer. His doctor uses a series of methods, including a model, to decide his prognosis.

In Situation 1, his doctor uses the “precautionary principle” and presents the worst-case scenario based on a model of the worst case: J has about six months to live.

In Situation 2, the doctor bases her prognosis on future-projecting J’s present situation, by definition not the worst-case scenario and more “optimistic”: J has another two years to live.

Which scenario is better?

The answer isn’t so straightforward. In medicine, prognostication is fraught with its own challenges and depends largely on the data and model used, which may not perfectly apply to an individual patient. More importantly: The patient is part of the model. If the information used then shifts the patient’s behavior, the model itself changes–more precisely, the weights given to certain variables in the model change either toward a more negative or positive outcome. In the first scenario, J may decide to shift his behavior to make the most of his next six months, perhaps extending it to nine months or longer. Does that mean the model was inaccurate? No. It does mean that knowledge of the model helped nudge J toward a more optimistic outcome. In the second scenario the opposite may happen: J may continue his two-pack-a-day smoking habit, or only cut down to a pack a day, which may hasten a more negative outcome. It’s entirely possible that J in Situation 1 lives for two years, and in Situation 2 lives for six months.

This pattern exists everywhere, from prognosticating climate change to even polling (knowing poll results can affect voting behaviorpotentially changing the outcome). We’ve seen a similar dilemma with Covid-19 pandemic modeling, which may help explain the divisiveness over everything from when the pandemic may end to whether lockdowns are appropriate. Last year, just as the World Health Organization declared Covid-19 a global pandemic, I wrote about uncertainty and risk perception. When faced with uncertainty we defer to experts, but a month later the National Institute of Health’s Anthony Fauci correctly noted that experts are fraught with predicting what was (and still is) a “moving target.”

Over the past few weeks we’ve seen more opinion pieces focused on optimism: that herd immunity will be reached by April, and summer will be more like 2019, wide open and carefree. We’ve also seen how this optimism, based on a “present-day accurate model” can sway behavior: from schools opening (but then locking back down) to Texas’ recent removal of its mask mandate potentially contributing to an uptick in cases. Others have taken a more pessimistic approach, saying it may be another two years until things “return to normal,” and the virus variants are a “whole other ballgame.” Today, in Michigan and in Canada, a potential variant-fueled third wave suggests a less optimistic outlook (for now). We’re all deeply familiar with how this pattern has repeated itself several times over the past year, and even experts disagree (and some have changed tack). It’s more than just bad news bias. But how do we reconcile this dichotomy between the “optimists” and the “pessimists”? It may come down to how we understand the purpose of epidemiological models in general, and the two types of pandemic forecasting models.

Justin Lessler is an associate professor of epidemiology at Johns Hopkins University and is part of a team that regularly contributes to the Covid-19 Forecast Hub. He specifies that there are four main types of models: theoretical, which help us understand how disease systems work; strategic, which help public officials make decisions, including to “do nothing”; inferential, which help estimate things like levels of herd immunity; and forecasting, which project what will happen in the future based on our best guess how the response and epidemic will actually unfold.

When it comes to forecasting models, there are those whose forecasts are not worst-case scenario by definition (thus more optimistic), which aim to describe present-day patterns in transmission and susceptibility and project out, assuming the current patterns stay the same. In these “dynamic causal models” a variety of different variables are added to also include, as University College London based biomathematician Karl Friston described, unknown factors that affect how the virus spreads, dubbed “dark matter.”

Then there are forecasting models guided by the “precautionary principle,” aka “scenario models,” where the assumptions are often the most conservative. These account for the worst-case scenario, to allow governments to best prepare with supplies, hospital beds, vaccines, and so forth. In the UK, the government’s Scientific Advisory Group for Emergencies focuses on these models and thus guides policy around lockdowns. In the US, President Biden’s Covid-19 task force is the closest equivalent, while the epidemiologists and actuaries that appear nonconformist may be the closest we get to a group like the Independent SAGE (which Friston works with).

“The type of modeling we do for the Independent SAGE is concerned with getting the granularity right, ensuring the greatest fit–with minimal complexity–to help us look under the hood, as it were, at what is really going on,” Friston told me. “So, the fundamental issue is namely, do we comply with the precautionary principle using worst-case scenario modeling of unmitigated responses, or do we commit to the most accurate models of mitigated response?”

This gets to the heart of the tension between various “experts.” For instance, epidemiologists like Stanford’s John Ioannidis have tended to be more concerned with modeling the pandemic to accurately explain current patterns (and extending this pattern into the future), which can come off as more optimistic and isn’t typically used to guide policy.

**Originally published in Wired, March 2021**