The Derek Chauvin trial highlighted a potential way physicians could better serve the criminal justice system
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.
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.
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 behavior, potentially 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**
How to make sense of recent concerns about the AstraZeneca vaccine
Last week, several European countries paused their use of the AstraZeneca vaccine due to concerns about clotting and bleeding risks. Though the World Health Organization (WHO) and European Medicines Agency (EMA) have both said that it is safe to use, most countries have resumed using the vaccine, and the company released data on Monday showing it is 79% effective in preventing symptomatic disease in the United States, many people may still be wondering about the risks. There are five major things to clear up when understanding the concerns about blood clots.
1. What are clots?
When most people think of blood clots, they think of a scab on the skin or clots in menstruation: congealed, thickened blood. In medicine, we’re talking about something more serious, involving the blood that circulates in our veins and travels from the tissues to the lungs to get reoxygenated. Blood clots are a general term for what’s known as deep vein thrombosis (DVT) and pulmonary embolism (PE).
Think of DVTs as blood clots that are often found in the calves or in the arms. Sometimes they resolve on their own, but they become dangerous when they break off and travel through the circulation and into the lungs, causing a PE, which in turn causes chest pain, decreases oxygen, and can lead to death. Sometimes DVTs can break off and travel backward to the heart and through the body again, making their way into the brain and causing a stroke. This is called a paradoxical embolism. A more rare clot in the brain is called a cerebral venous thrombosis (CVST). CVSTs may be the main clot of concern associated with the AstraZeneca vaccine. DVTs, PEs, and CVSTs are medical emergencies.
2. How do clots form?
Most of the time, blood clots form in order to help us heal from wounds — injured tissue, internally or externally. Their formation involves the “coagulation (fancy word for clotting) cascade,” which comprises the extrinsic pathway, intrinsic pathway, and common pathway. The extrinsic pathway refers to factors in the coagulation cascade that are external or extrinsic from blood when studied in a test tube. The intrinsic pathway refers to factors in the cascade that are found in the blood when studied in a test tube.
These pathways require many components to work together effectively, including various clotting factors, most of which are named using Roman numerals and some that aren’t, like protein tissue factor (TF) and Von Willebrand factor (VWF). Other proteins block abnormal clots from forming, so they are said to have “anticoagulant” effects. These include Protein C, Protein S (both work with Vitamin K), and antithrombin III.
Some individuals bleed more easily than others. This can be due to deficiencies in coagulation factors — Factor VIII and Factor IX deficiencies, for instance, cause hemophilia, as does a deficiency in VWF. Other people have a lower platelet count. Since platelets are important to forming a “clotting plug,” which helps prevent blood loss by temporarily sealing an injured blood vessel, a dip in platelets often means bleeding risk may increase.
3. Who is at risk of clots?
Glad you asked. First, anyone with a deficiency in an anticoagulant is at risk. Put another way, anyone who doesn’t have clotting blockers or who clots easily is at risk. An individual with antithrombin III deficiency, for example, would typically clot more easily.
But someone can have perfectly normal coagulation factors and a perfectly well-oiled coagulation cascade and still be at risk. Many athletes (as I’ve written about previously) fall into this category. This brings us to Virchow’s triad. Over a century ago, the German scientist and physician, Rudolf Virchow, described three components that increase the risk of a blood clot.
The first is “venous stasis,” which refers to moments when the blood sitting in our veins is stagnant. Imagine honey or ketchup in a squeezy bottle that’s stuck because it’s been sitting around. The way ketchup or honey congeals is similar to how stagnant venous blood forms. Except in the body, this can lead to a clot. In humans, this happens when we are stagnant. Long flights where we aren’t moving around is a common situation, but so is lying in a hospital bed for days on end, which is why many patients receive a blood thinner and are encouraged to move around.
The second component is vessel injury. If a blood vessel gets injured, the body responds by forming a clot, much as it would if you injure your skin through a scrape or a dog bite. Except when this happens in the body, there’s a chance the clot can become large and break off, blocking vessels and preventing blood (and therefore oxygen) from reaching the tissues, which can be deadly when it comes to the lungs or brain. These blood vessel injuries often happen during surgery.
The third factor involves other factors that increase hypercoagulability, which can refer to everything from cancer to inflammatory disease to being on estrogen hormone therapy (like the birth control pill). The mechanisms vary, but they are generally due to the impact on components of the coagulation system that drive it toward more clotting and away from anti-clotting.
4. So, how does this explain the concern with the AstraZeneca vaccine?
Everything! We’re almost there. Let’s get some facts straight first. First, the incidence of DVT and PE, due to the issues described above, is about one per 1,000 people per year. For CVSTs, it’s even more rare: five per 1 million. This is the normal pre-pandemic and pre-vaccine incidence and reflects individuals at risk due to Virchow’s triad and issues with their coagulation system.
Back to the vaccines. Robust vaccine monitoring systems in many countries specifically look for potential adverse events after the vaccine, as part of what is called “active surveillance.” In general, however, we don’t have active surveillance for blood clots. No one calls families randomly to ask if anyone has had a blood clot. So, the fact that about 37 people who got the AstraZeneca vaccine have reported blood clots, out of 5 million who received the vaccine, doesn’t necessarily mean it’s caused by the vaccine. In all likelihood, these same 37 people would have had the same blood clot even if they weren’t vaccinated. And this is likely, given that the rate isn’t particularly high, compared with the baseline risk of blood clots. While the year still has nine months left, the current rate is about 0.006 per 1000 people per year for clots in general, which is lower than baseline.
It’s possible, given that the AstraZeneca vaccine is generally easier to store and manufacture in larger volumes (e.g. by India), that more people in total have received it. If that is the case, it may seem like the AstraZeneca vaccine is associated with more clots compared to the other vaccines, but the reality could be that more people have received it, period.
The Pfizer/BioNTech vaccine has been given out in 72 countries, and AstraZeneca to 71 as of March 18, but the number of people who have received it in those countries is not known. If each vaccine were distributed with the same frequency, it would be much more straightforward to compare the rate of adverse events, and it’s possible we would see the same pattern with them (which isn’t much of a pattern at all if it’s less than or equal to the baseline risk).
This is where the Bradford Hill criteria of causation comes in. They essentially say that temporality — the fact that an outcome comes after an exposure (in this case, an adverse event comes after a vaccine) — isn’t sufficient to prove causality, for the same reason that wearing a yellow T-shirt a few hours before the sun comes out doesn’t mean your T-shirt caused sunshine. We need more. Specifically, a biological gradient and plausibility: A biological explanation for the cause, much like we know that smoking causes lung cancer because the elements in cigarette smoke are known to be carcinogenic (even in a lab, they can cause mutations in lung cells that result in cancer).
5. Putting it all together — three key questions
Now that you’re an expert in clotting and causality, we can ask three crucial questions.
The first is whether the incidence of blood clots is statistically significantly higher among those that received the AstraZeneca vaccine compared to those that received no vaccine or another vaccine. (Statistically significant means that it’s unlikely to be due to chance.) Here’s the easiest way to think of it: In a random sample of 1,000 individuals, half of whom received the AstraZeneca vaccine and half of whom received another vaccine or no vaccine, does the AstraZeneca group show a statistically significant increased incidence of DVT, PE, or CVST? When testing a large number of rare events, the Bonferroni correction must also be applied to avoid the erroneous finding of statistical significance when testing several things, which apparently was missing from the EMA’s initial work.
The second is whether the dip in platelets observed in people who got the AstraZeneca vaccine is different from what is seen with other vaccines and viruses. Viruses, in general, can sometimes cause temporary dips in platelets (known as thrombocytopenia), and vaccines that are made from inert viruses may also do this. Though they usually cause a mild decrease in platelets, a severe decrease can be concerning and can cause a paradoxical overactivation of platelets, which can cause clots.
The third is whether there is a component in the AstraZeneca vaccine that would impact the coagulation cascade, specifically the hypercoagulability element of Virchow’s triad. This seems unlikely as most vaccine adjuvants (which boost the “immunogenicity”) and stabilizers are inert, meaning they don’t have medicinal or biological impacts. Alternatively, finding other biological mechanisms to explain the body’s abnormal response to the vaccine is also possible.
In summary, it’s unlikely that the clotting issues discovered by active surveillance are caused by the vaccine. However, it’s understandable why some countries are pausing vaccine administration until the above three questions, and possibly others, are answered.
The WHO continues to back the vaccine, while the EMA simply wants to add a warning, and countries like Canada are considering updating its guidance. The crucial thing to understand is that in a battle of risks, the harm from halting a vaccine campaign aimed at putting a stop to a deadly pandemic, which has a risk of mortality and long-term complications, appears to be much higher than the risk of blood clots.
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
Parlaying a cancer diagnosis into an advocacy powerhouse, Ann Marie Giannino gives voice to people impacted by breast cancer, MS, and mental health issues. Since establishing the non-profit Stupid Dumb Breast Cancer organization in 2012, AnnMarie has worked tirelessly to engage the community through awareness programs and fundraising initiatives, and to ensure that everyone who suffers is heard. She currently serves as Director of Communities for Wisdo.com. Wisdo was created by Boaz Goan, in memory of his father, Benny Goan, who touched many with his wisdom. Goan wrote about the origin story and mission of Wisdo for Medium in 2016, writing: “Wisdom is practical knowledge. It’s what’s learned in hindsight. Kernels of “if only I had known then what I know now” information meant to pass along so that others can benefit.”
Amitha: What has the response been so far? And growth patterns (including by age but also geography — are some countries/regions more on board vs others)?
For me personally I have watched and nurture Wisdo from the start. We had ten guides when the platform started to over 100 now and over 3,000 helpers. We are global for sure USA and UK seem to be our strongest. The age range is amazing. 19 to 70!! I love the fact we can connect with so many ages to share a common story. There is truly something hopeful talking to someone older than you who has gotten through a really hard time. We have over 1.5million registered users now – the community is growing and thriving.
Amitha: What has the impact been, in terms of general comments and any measurable things (research if available — has it made a difference among people with diagnosis of depression or those with depressed mood that is self-described?)
Annmarie: Again I would like to speak about the community. Wisdo is this amazing safe space to talk about things that are hard to hear. Many regular users on other social platforms don’t get seen because of the algorithms, and the follower count. By creating an environment where our members feel safe to express their dark thoughts we have instantly helped. Not talking and hiding behind safeguards will only perpetuate the stigma and make those living with depression feel alone. Wisdo does the opposite. We show those living with many mental health crises that talking is just what they need and talking to those who have been there can show them they will get through. This also validates what they are going through, they can see in our community that they are not the only ones feeling this. What an amazing way to show people that talking is safe and that even though their depression may look different we all are going through something similar.
Awhile ago a girl – a 19 year old who just got out of rehab has posted in a ‘coping with addiction’ group. And her recovery was similar to them. I clicked “Been there” (a button on the app). And she replied and said “thank you for reacting to my post.” And I replied. So here’s this 19 year old looking near a 40-something year old and got so much hope. We need that so desperately. When you sign up for a support group, regardless of age or ethnicity, but you’re all connected based on a similar experience. We get a lot out of knowing someone’s story, so for the most part it’s a peer-to-peer support. It’s not about misery loving company…people with depression want to connect to people who know what they’re going through.
Amitha: What are your thoughts on the general trend, if you agree it’s a trend, of social media looking at ways to i)decrease its toxicity/addiction potential ii)improve mental health and well-being? What other apps/companies are thinking about the same problem and seem interesting to you? Social media has 100% made Mental Health “trending”.
Annmarie: The issue is while the general public sees this as a plus those who work in the mental health world see the problem. We are looking at pretty images of depression on IG, we see all the likes some get for posting, our world is at an all-time high for substance use disorder because it is “5 o’clock” somewhere, Eating Disorders have skyrocketed and domestic abuse is immeasurable right now. With the wave of COVID we will not know the true impact of how it has affected Mental Health for at least 2 years. We are living in an age where likes are giving many anxiety because they are not getting enough. Wisdo is not about social competition but connecting with those feeling like you do to help you see you are not alone.
Amitha: In 5 years where do you think social media in GENERAL (so the big names like Facebook, Instagram etc) will look like? And will they me more aligned with apps like
Wisdo, or will they be obsolete, i.e. replaced with platforms that connect people in healthier ways?
Annmarie: Personally I have seen a change in Instagram but more on the silence side. They are block certain # because they are scared of the conversations. If other apps would take in how Wisdo creates a space to have a real honest discussion about self-harm with healthy alternatives and understanding why this happens we would be ahead of the game. I think as we go into the next 2 years Instagram, Facebook TikTok will all have shifts. Mental Health workers and advocates are looking for Wisdo like platforms to send people to just to connect because crisis lines are overwhelmed. While Instagram and Facebook use moderation tools to watch their platforms TikTok is using algorithms which has proven to be problematic. Wisdo uses moderation with watchlist words that our team of volunteers keep an eye on. Our community supports each other and wants everyone to be heard. We have done an amazing job of letting people express themselves while keeping our community safe.
Amitha: What are you most excited about with Wisdo and what’s on the horizon that you can discuss now?
Annmarie: I remember a long time ago saying to Boaz “Wisdo has no personality” I think this bothered him a little bit, however what it did was show our team what was missing. Wisdo is alive with helpers, guides, coaches all wanting to engage the community. Watching Wisdo embark on some exciting new projects that will not just bring in members but a diverse group is really impactful. We all take a breath the same way and sometimes we forget that. Watching older adults come into the app and give their story to young adults is truly inspirational!
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
From her work on the initial Sephora team to her experiences in manufacturing, consulting, and brand strategy for companies like Gap Inc., Cisco, and Landor, Melody Mortazavi has been passionate about creating brands her entire career. Mortazavi is an entrepreneur who believes in the power of connection, and she founded UME in Menlo Park with that vision in mind. After UME was acquired, Mortazavi continued to pursue her love of brands and human connection by co-founding Longwalks with Trishla Jain.
Trishla Jain is an author, artist, and entrepreneur. Throughout her career, Trishla’s work has focused on helping people communicate and connect mindfully. She is an author of a mindful children’s book series and an accomplished artist with exhibitions exploring the intersection of joy, gratitude, and minimalism. Trishla sought to build a better way to spark meaningful conversations and deepen personal relationships online, co-founding Longwalks with Melody Mortazavi.
Amitha: So I downloaded Longwalks back in December, and I can’t remember where I had first heard about it – it might have been through Oprah magazine or a tweet she posted? It’s so well designed, and I love the concept. What got you motivated to create it? And what spurred the interest in well-being and self-care?
Melody: I think that we approached this in a very personal way to start with. We (Trishla and I) met quite serendipitously, and she had invited me to a conversation, sort of a Jeffersonian type dinner, at her home, where she had crafted a really beautiful conversation for the evening. The conversation was designed to bring 10 women together who had never met before in the most optimal way possible. And yes, that's very “Silicon Valley,” but like everywhere else in the world we're all quite pressed for time and so she wanted to create the perfect environment for us to really get to know each other. And that meant getting to know each other outside of what we do or what our significant others do or where our children go to school, which are the typical things you generally hear from each other when you first get to know someone. There was a question that was posed about a poem that grounded the conversation, and each person just shared, one at a time, as we went around the table, about a story that that poem reminded them of. It was a very new way to have a conversation because you actually got to sit there and really listen to what the other person was saying. And then when it was your turn, you could speak essentially your truth. And so, this form of uninterrupted one-direction type of sharing was really beautiful. It was really transformative for me, and I had never been in a conversation with someone else or a group of people where I didn't actually have to work very hard to keep the conversation going. And this was just a really beautiful way of connecting with other people at the table, and after the third or fourth time we had done this, I started thinking about the ways people are connecting with each other now digitally. So we started thinking about how to deliver this same sort of experience to others. I think, when social media was designed and developed, people didn't really think about the negative impact on mental health. They didn't think about the impact on people's relationships or attention spans, and all the things that you very well know. So we embarked on this very ambitious mission of creating a truly supportive and kind social platform where people can share their stories in a way that I was alluding to, to really tell the things about themselves that really matter to them and make up who they are: like the really the good juicy stuff of who you are. And so I think what we did really beautifully was really utilize psychology, Eastern philosophy and a lot of really mindful meditation practices to create a platform that not only provides the content that's that really helps people connect, but also create this really beautiful safe space which we hear about time and time again.
Trishla: I mean your question was really why we started Longwalks, and in essence I think the quality of our human relationships, the depth and intimacy of them is one of the primary indicators of lifelong long-lasting happiness and kind of what the Harvard Study of Adult Development says.
When you look back, a fulfilled life is one with beautiful deep relationships. So that's really kind of the vector where we wanted to focus. It all came together in this beautiful way. And the way Longwalks is really different is that in some sense it's not open-ended, unlike every other social platform where you can kind of share whatever it is you want to share, using various formats. We've really created a little bit of a cocoon around the user using our prompt. So, we provide one single piece of content, which is a fill-in-the blank question every day. And that's it. It's very simple. It's very equalizing pretty much being a human. I've had a lot families say that they do it with their kids. They do it on their phone with adults and then at night they use it at the dinner table, and they make all their little kids like six year old, seven year old, kids fill it out. So it’s kind of just like a moment where you get to share something and then we anchor we map out the whole year. In 365 days we kind of cover a large aspect of what the human experience. And it's beautiful because you don't really have to think about what you're sharing and get yet if you're doing this with people on the platform. You get to experience humanity and living together.
I think that I've been practicing this formula of sort of asking a question and then making everyone answer it in the fill-in-the-blank model for a very long time, since high school, so it's just kind of my modus operandi. This was the first time I had kind of done this in Silicon Valley and Melody happened to be there, and then with serendipity, one thing led to the other and in 2017 Melody started to think of this as like a full-fledged business rather than just a private kind of experience with friends, but by then we must have had over, 250 of such dinners like that. And the digital format kind of coincided with COVID, even though it started way before COVID it just, there's so there's a lot of serendipity in our journey.
Melody: What matters is that the question has to be supportive enough for people to want to access that as a nugget to share it with somebody else, so 2017 was a year of focus grouping, really, essentially, and then figuring out how we want to how we want to deliver this what it would look like, as a feeling to bottle up. I think one of the beautiful parts of the digital platform is that you can have that feeling with someone, all the way across the world, who has like a completely different socio economic background is of a different race and gender and every everything is different about them, but you can actually have that exchange of that feeling with that person. And that's what's happened to me a lot -- I've randomly met probably 20 or 30 people who are now my friends on Longwalks, that I share with, and I don't even know where they live!
Amitha: That's amazing. I was just talking to someone about on most apps or social media there aren’t really incentives to be civil. And I’ve likened it to a dinner party, where if you aren’t civil, even if you have opposing views, you won’t get invited again. But there’s this feeling where it's almost invigorating when you have a really interesting discussion or debate, or you know that feeling of being connected. So you're, totally right – it’s super hard to get that online with a lot of the apps that are out there right now that are being used.
Trishla: I read that you're also Yogi and you love yoga. And I think with Longwalks it’s that synchronicity that sometimes gets missed. Like when you're in a yoga class, the entire class is participating in a series of motions, everybody's on the same page and moving together. And that creates a very harmonious flow. It's not like everybody's doing their own thing. One of the most unique things about our platform is that everybody's doing the same ‘pose’ as in answering the same prompt. So you feel you're not alone, like you're just all different rays of the same sun.
Amitha: I love that analogy. So the actual digital element was that rolled out in 2020 then you're saying just around the pandemic?
Melody: The first version of the app was launched in August of 2018. We had been working towards a solution for a couple years before the pandemic hit.. What we've done really mindfully is that we are building this app for our users, and we have a big cohort of users who really love this app. And so we build and we iterate based on their needs, that you know of course are aligned with, with the mission. So we have taken quite a few updates and changes to the app in order to best align with our with our users, and when COVID happened and we all went into lockdown in March, had just launched our best MVP (minimum viable product) to date. And so we saw this really beautiful alignment of user with product. And that's when we had a significant uptake in users, and we have really great App Store reviews that are all organic and just people's real experiences. So, the alignment was really great, during a time where it was so uncertain for everybody. We were providing a tool that was helping people feel better. That was helping people feel connected to each other not as far apart, was giving them something to anchor their daily practices so that they could answer something with the people in their lives. And it was really helping them stay close to the people they couldn't be close to. And so that really gave us a whole big lift in order to kind of keep going and keep building and keep doing what we're doing
Amitha: Why the name Longwalks?
Trishla: Many reasons. Some of them are practical, you know, in the sense of wanting to have a name that's unique and all of that, but really Melody and I are just nature lovers who love to walk and we think of human relationships as kind of like walking hand in hand. And we think that sometimes the best conversations you can have is when you're on a long walk with a friend. Because the conversation just organically flows, and you're enjoying the earth, so there's many different kind of connotations. I don't know -- Melody what does the name mean exactly?
Melody: I will just embellish a little bit more in that I think that the experience we try to mimic on Longwalks, is really that kind of those special moments that you have during a long walk, you know those really those heartfelt conversations that you really get to know people that's essentially I think what we hope toreplicate.
Amitha: How do you feel like, like how is the uptake been so you obviously launched in 2018, you were saying, um, have you seen an uptake. I mean, as I mentioned, I've heard about it. I think through either Oprah Magazine or something, some something over related.
Melody: She gave us a shout out! Oprah’s a gifted conversationalist and gifted person at making anybody feel important and worth listening to. And I think we've always just reached out to her along the way when we've needed guidance or calibration or just talking to someone whose life's work has been about helping people connect meaningfully.The shout out was definitely a big surprise to us- we had no idea it was coming. And I think I was on a long walk at the time because I hike a lot on the weekends, and our biggest concern was ‘oh my God are the server's gonna crash?’ Luckily they didn't and our tech team, they're all just incredible. So, it was a great shout out from her that kind of validated the experience that all the users were having. They were really grateful for Longwalks during a time where there wasn't a lot to be grateful for.
Amitha: Definitely. So have you found during this pandemic that uptake has increased like? Because apps are tough in terms of getting people to stay on them. But I think that what you're offering is unique, so I would hope that there's more people are more incentivized to like stick to it.
Melody: I mean I think that's where we started the conversation is ‘How do you have social wellness’ and ‘what does that even look like’ as in having a healthy relationship with this phone and the things we do on it. And I think that one thing we try to do as we definitely don't hold ourselves accountable to the same vanity metrics that other social companies, hold themselves accountable to. So for us time spent on app is measured a little bit differently for us, because it's important to have a depth of relationship. We don't make it about Facebook likes or friend counts or friends lists and things like that because it's just, it's a different platform it's a more niche platform and I think our goal is to empower the depth of relationships and authentic connections, and helping people find like-minded people on Longwalks. When we are looking at acquiring users we unfortunately have to use the same mediums that other people use, and do your standard performance marketing things but the way I sleep at night is to think that I am leveraging these other social media platforms to bring people to Longwalks. It’s a healthier and better way to communicate with the people that they want to communicate with.We don't expect to take over. So the time that you spend on Instagram or Facebook we just hope to kind of counterbalance it with things that fill your bucket and make you feel really good about the people that you're talking to.
Amitha: I'm sure you both watch The Social Dilemma. I'm sure it's not a surprise, in terms of what they presented, but do you have any thoughts on sort of how Longwalks fits in? I guess you've sort of answered that question as it being a buffer or counterbalance?
Trishla: Tristan is one of the early attendees to dinners. And at the end of the dinner he shared a very profound experience about his mother and said ‘I challenge you to bring this to tech as I've never seen it.’ And at the end of The Social Dilemma they pose a question, you know, as in ‘what is the solution?’ They don't offer solutions. So we really feel like Longwalks is very sustainable, because it only takes a few minutes maybe 5-10 minutes a day. It's a very sustainable solution to create social wellness in your life, using your phone.
Melody: I think it's just a really actionable solution. So that's how we think of it as well, in relation to The Social Dilemma, and Longwalks is literally designed as an antithesis to all of the problems of social media. So, it's designed to not feel like a popularity contest -- we don't display any kind of counts. We don't publicly display how many people have liked your post. We don't let you know how many friends people have or any kind of numerical things like that. The way that our commenting works is that it's pre-scripted to be extremely supportive and kind. So it really eliminates that culture of bullying or negative commenting that occurs in other platforms. It's very unified like I said and has synchronicity because everybody's on the same page and answering the same questions. You don't get a lot of distortion or distraction there's no ads. There, nobody's trying to sell you anything. So a lot of the problems associated with social media just don't happen on our Longwalks: we've created a situation where they won't happen. But we always have our eyes open, just to see if things are creeping into that territory.
Amitha: Do you feel you're also sort of self-selecting as well for people that are not going to be that way maybe?
Trishla: We have the very committed and sticky users who use both regular social media and Longwalks, and then there are of course the people who doing a detox off other social media, so only doing Longwalks. So we find that it works really for anyone who wants to have a kind of new social wellness habit in their day.
Amitha: Got it. And then so you were mentioning I mean it sounds like when you, when you mentioned like Tristan Harris, for example, it sounds like you're pretty plugged into the Silicon Valley community so I'm curious to know like what your, what both of your backgrounds are in in tech, like a different form of tech before you could work for, you know, big tech before this like without a motivator. Tell me a little bit about that.
Melody: I actually come from a retail background and brand strategy background but during the latest part of my career I worked for Cisco and I did Internet Business Solutions consulting so I do come from a slight tech background but my specialty is really optimizing retail solutions for consumers. And then after I got pregnant with my first child I didn't want to consult anymore. I was not going to get on a plane every week, and so I decided I came up with this idea for a children's play space, and this was at the time where there were no other really placed bases around, so we raised a seed round and opened a 15,000 square foot children's indoor play space in Menlo Park called U-Me, so that I could work, and do something with my brain but also bring my kids to work. And so I did that for about seven or eight years and then that was acquired. Then I decided to go back into the corporate world.
Amitha: I'm just trying to imagine what it would look like in Silicon Valley like a big play space I imagine all of the, all of the activities are planned intentional and…
Trishla: Very. It was so beautiful I mean she has an unbelievable eye for design, they have this kind of minimal Scandinavian aesthetic where everything had a purpose, there wasn't any like random stuff and it was really the child was at the center of the experience and the child could direct it to play very well so, and she used a lot of that learning. I can see how she applies that user experience design in Longwalks.
Amitha: What about you Trishla?
Trishla: I grew up in India, and my family runs the Times of India group. So I kind of grew up
enmeshed in those walls. And then I went to an American school and then I came to the U.S. for college (Stanford) during college and fell in love with English literature, so I had a circuitous path where [I then attended Columbia University to do graduate work in education then] worked in brand marketing in New York. And after that, I went back to India and just worked at times in different capacities, learning about print. And then also learning a lot about how to embark into the digital world. I did that, and then I became a full-time artist, which is kind of my deeper love, where I had three solo exhibitions in India while having children.
Amitha: What sort of art?
Trishla: Painting. But during that time, I would say my main real job is being a full time Yogi. I did so many maybe 50 silent retreats like Vipassana. Yeah. Even a few 60-day ones where I left my husband with my parents. And I think that was just a time of profound growth intellectually, emotionally, physically and every way. And then we both moved here to America about four years ago. But we were thinking of it as coming back to Stanford, where me and my husband met. He runs the digital business of Times of India. Tristan is really more of a Stanford connection than a Silicon Valley connection.
Amitha: Got it. It sounds like you've had some really interesting experiences, both in India as well as in the US, and that blending of Eastern and Western practices in the sense?
Trishla: When you have profound meditation, it's almost like you just want to give back to the world in whatever way you can and then I found Melody.
Amitha: Yes, serendipitously! I'm such a fan of serendipity and have noticed that in my life as well. So obviously you both women of color – Melody you have Persian (Iranian) heritage, and Trishla you were born in India. How does that sort of affect or impact your experience in Silicon Valley as founders, anything that you want to share about that, like, in terms of opportunities or barriers?
Melody: So I think that if I had to talk for a moment about whenever I feel inadequate or when I feel that maybe I am not. I am not on par with the audience that I'm keeping has not necessarily been ever because I'm a woman, I think, for me it has always been a feeling that because I don't come from that so called White, tech, engineer, or a certain pedigree, I think that feels very heavy for women. I think that there's a certain level of...I think Trishla and I just don’t let it get to us, otherwise it becomes very demoralizing. So I think we do a very good job of tuning those things out and really making it about the product that we're building, and the solution where it could do with the solution we're giving to people. And because we are in a space of wellness, it makes it a little bit more comfortable, but for sure I would say it's very hard to maintain your confidence and not feel adequate being in the Valley and being women who are not from a pure tech background.
Trishla: I think one of the things my dad always taught me is that you have to turn your disadvantages into your greatest advantages. So in some ways, I like to think of it as this idea that we're fresh blood, like we never think of a solution on the product the way a veteran Facebook person or someone who spent 10 years at Google. And I think being mothers what matters is we care so much about building a future for our children. So we both have two young children, each and Melody's kids are older and she sees them already interacting with social media, and she wants to create a new alternative, kind of like a different way for her daughter to portray herself in the world. One option is for her to take a beautiful picture glowing skin and maybe comment on how sunny and beautiful it is in California on Instagram, and the other is to talk about maybe something totally different, something meaningful or something she's focusing on or, which is more Longwalks’ aim.
Melody: And people gravitate towards Longwalks generally are pretty open minded.
Amitha: One the things I’ve noticed when about individuals that are trying to make a difference in healthcare, almost all of them are described themselves as like outsiders. So people that early in life might have felt like they needed to fit in for one reason or another, because of their background or their way of thinking or whatever but over time they realize that those differences were actually an asset, and that was what sort of fueled them to think differently and make changes because as you can appreciate health care and the health system which is a very antiquated system. But the people that are actually making change are the ones that can actually see the solutions because they have an outsider sort of perspective. And I think, you know, it's our perspective and I also think it's a bit of grit as well like if you're someone that's used to adapting but you're also sort of like you're maybe a little bit grittier as well. I think that that's super interesting that you both seem to identify with that as well. Was there anything that I didn't ask you that you think is really important.
Ok my last question! Because I have an epidemiology I'm always interested in research. Have you thought about looking at the data in terms of assessing how people are feeling using the app? Could it be an intervention or studied in some way in terms of short and long-term impacts on mental and emotional health? Or do you have a sense of this already?
Trishla: I would say intuitively, qualitatively, the feedback indicates a resounding yes, that people see a kind of marked uplift in their emotional states, reduction in depression, reduction in anxiety, and loneliness. However, it would be a dream come true I think for Melody and I to have that documented in a way that's actually scientific with rigor.
Melody: We're looking at a way actually to incorporate these questions into the user journey to get a sense of how it has impacted them and the main reason we wanted to do that was just so we can make sure that we are staying true to their needs and really able to satisfy kind of those things so we are looking into it right now. I think given the pandemic and everything that's happening, I just feel a little uneasy asking users to fill in those questions. But definitely I think going down the line, it’s something we will be doing.
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
Miri Polachek is the CEO of Joy Ventures, the start-up studio building, funding and supporting companies developing consumer products for wellbeing. Miri joined Joy Ventures as CEO in 2018, bringing with her an extensive background in health and finance. Prior to Joy Ventures, Miri amassed a decade of experience in the pharmaceutical industry, working in financial management at Teva Pharmaceuticals and Pfizer and serving as VP Finance at healthcare services firm IntegraMed. She co-founded and served as the Executive Director of Israel Brain Technologies (IBT), a non-profit organization envisioned by former Israeli President Shimon Peres that accelerated brain-related innovation and positioned Israel as a leading global braintech hub. Miri holds a BA in Economics and Mathematics and an MA in Health Economics from Boston University, as well as an MBA from New York University Stern School of Business.
Amitha: I’m so interested in what brought you into this field, and what you think is on the horizon in terms of the intersection of well-being and tech. Can we reverse some of this damage that we've seen from technology? Is it about investing in companies that are focused on tackling this issue?
Miri:I've always been very passionate about health and health care. My mom is a neuroscientist, and my dad is an engineer and high-tech entrepreneur, so, science, technology and entrepreneurship were always conversations at the kitchen table. While I actually studied economics and finance, I found myself working in the healthcare industry because I was always very passionate about improving people's lives. I initially found myself in the pharmaceutical industry and then worked in various financial management roles in a few large global corporations. But over the years, mental health and brain health became a very strong passion of mine, in part because of having this strong neuroscience presence at home and having worked on product teams at both Teva and at Pfizer, but also because of having a brother living with a mental illness.
When I moved back to Israel 10 years ago, I jumped into the start-up ecosystem, and established and led a non-profit organization called Israel Brain Technologies, an initiative whose mission was to position Israel as a leading neuroscience innovation hub, specifically by commercializing Israel’s brain-related innovation. There, I helped run an accelerator focused on brain technology start-ups, and a very successful international conference that brought together the entire ecosystem of researchers clinicians, entrepreneurs, and investors. Working there was an amazing privilege, and several start-ups that went through the program have advanced in their development and some are already succeeding in the market.
Then about three years ago, Joy Ventures approached me to join them. I was already familiar with Joy, having been part of the same community interested in innovation in neuroscience and what Joy was calling “neuro wellness” at the time. Joy Ventures’ cared about understanding the healthy brain better in order to understand how we deal with stress and how we can improve our emotional wellbeing.
Amitha: I was really intrigued by Joy’s vision, because it takes an approach of looking at the science or innovating effective solutions that are not simply passing trends or gimmicks.
Miri: The word “wellbeing” is really something that we at Joy Ventures want to back up with technology that works, that makes a meaningful change in people’s lives, and that is enjoyable to use. Many wellbeing products create a nice experience, but the question is whether they actually create some kind of a change for the user. This could mean helping them relax or helping them sleep better, etc. This driving factor was what brought me to Joy in early 2018. I was first and foremost intrigued by the vision, which was to build a portfolio of companies that would help people feel good. At the time (several years ago) however, this sector was still very young, so the challenge was how to actually find companies that match our vision. At the time, we were looking primarily in Israel and there weren't that many companies back then, even worldwide, that fit our mission.
Some of the companies that are now unicorns were just starting out in 2018 and hadn't yet proven themselves in the market. There were a few companies that were starting to become household names. The Joy model is very much about incubating new companies, which means finding companies very early on and helping them develop their product concept, validate their ideas with users, and then gradually go to market. We also work to create awareness and community around innovation in this space.
Over these last three years, Joy Ventures has evolved as an organization; we've expanded our scope. While we are based in Israel, we invest globally. In fact, over the last year, we made our first investments both in the United States and in Europe. We just recently invested in a company based in Boston and founded by MIT researchers called Embr Labs, who created a thermal regulation wrist wearable that helps people adjust their body temperature sensation.
Amitha: It’s a form of biofeedback?
Miri: Yes. The wristband allows you to better regulate your temperature in terms of hotter or colder. In the future, Embr Labs also plans to enable a sensing or a closed loop capability. The wristband can help with sleep and is currently primarily being used to help “primetime women” in the menopausal stage, in which they are experiencing hot flashes. We also recently invested in a UK-based company called Empathic Technologies that created Doppel, another wrist wearable that helps to generate calm through haptic technology involving vibrations to your peripheral nerves. These vibrations, when at a high frequency, imitate your heartbeat, so it can cause the brain to either become more stimulated or calmer.
We're now also taking a much broader look at wellbeing, interpreting that word very broadly in order to pursue technologies or products that create some kind of meaningful change for the user through a delightful usage experience. This includes emotional wellbeing, physical wellbeing, and social wellbeing, which is one of our main focuses in 2021 due to the ongoing pandemic. We expect that social wellbeing will be one of the main issues this year compared to the past as loneliness and social isolation continue.
Amitha: That's an interesting topic because social media, to a degree, has been really helpful for some people during this pandemic to feel more connected, but we also know that there are issues with social media too and there's almost like an inverted U-curve or something: it’s dose dependent perhaps?
Miri: Definitely, and I think it's both dose and content dependent. We recently invested in a very exciting company that created a different kind of social network focused on rewarding those who are helpful rather than those who are popular.
Amitha: Do you think that these sort of apps that focus on well-being online can translate to offline social behavior? Specifically, in terms of creating connections offline. Yeah, so I guess what I'm thinking of is, for example, the recent riots in the US, on January 6th. There was a lot of talk about how it was planned online. So, it has me wondering if, since toxicity can build online, which translates offline, can the opposite be true? Can empathy and understanding those different from us, if built online, translate offline?
Miri: Yes, I would agree that if we create good online, it would reinforce positive behaviors offline. This is why, when we look for future investments, we also look for products that combine the physical and digital worlds, especially in terms of how they facilitate contact with another person. For example, the startup Noom is a weight loss program that includes both a digital aspect via an app as well as a personal interaction with a real group coach. This real-life interaction creates a more natural relationship and a higher level of accountability.
Amitha: So what do you think are the big trends as it relates to well-being and tech? You wrote an article in Fortune that came out in August about emotion-tracking apps. Was there anything you would add to that?
Miri: I think that a major trend in 2021 will be technology that creates connections – like products that help us stay in touch with our loved ones and our colleagues remotely, and anything that helps people create and maintain relationships on a more significant and deeper level. We recently announced which is you know helping grandchildren and grandparents, you know, connect and maintain their relationships, better. So I think that's the whole sort of connectivity from IQ, you know, maintaining these deeper relationships is going to be.
We're already seeing a lot of this technology take off. There has been a lot of traction around corporate wellbeing and solutions designed specifically for the workplace, that help maintain corporate culture and connections in a remote environment. If in the past employers’ premiums or health insurance grants were reduced because they’ve got an office gym, now this trend is expanding and offering a lot more through the corporate environment.
Amitha: Just at the start of the pandemic, around March or April 2020, I did a little interview series for Mind Body Green, interviewing different sort of public figures around what they were doing for their well-being. Almost everyone talked about routines, which I think is what you're getting at: these little moments in the day when you can sort of build in something to keep your routine that keeps you well and keeps anxiety at bay. I mean, again this was very early in the pandemic but it was interesting to hear that people were already understanding that the only way that we can sort of get through this is if we have a good sense of what our days are going to look like. This fits into well-being and all of that sort of thing. What do you think is one of the biggest challenges or barriers to this marriage between tech and well-being like?
Miri: I think the biggest challenge is the burden the tech developers and creators face in gaining the trust of their customers by proving that the products they created have a studied and tested impact. Some of these companies, especially those that are bringing in new approaches and new technologies, need to educate the market a bit before gain consumers’ trust.
Amitha: I wanted to end with a two-part question. First, how are you doing with all of this especially someone in the well-being space? Maybe you're doing better than most? And then the second part is: what are things that you build in personally in your day to keep you well during this time.
Miri: Thanks for asking. One thing that I always say about myself is that I was blessed with natural resilience. From a young age, I developed some strong coping mechanisms that have helped me handle stress and uncertainty, including during this challenging time, and I'm very grateful for that. There have of course been times during this past year that were really scary, and primarily I've been worried about my children. I think that depending on their age, not all children have those kinds of necessary tools to deal with all these changes yet. I have three kids who are extremely social, and it hasn't been easy to be separated from their friends so constantly. But thankfully, my whole family has been healthy. I think if we can teach our kids tools to cope with stress in different ways, they are much better off. Joy Ventures as an organization has luckily also been able to continue operating, though remotely. We feel blessed to be healthy and employed, and so I don't think we can ask for much more.
What I do for my own well being is highly conventional. I exercise, meditate, and try to spend a lot of time outdoors in nature. We live near the sea, so I like to spend a lot of time walking on the beach and sailing. We also have a lot of parks in Tel Aviv and I like to be around the greenery. I'm also lucky that I sleep well and I do make sure to get enough sleep.
A physician’s suicide reminds us that the plague of COVID-19 creates deep emotional wounds in health care workers
One of the oldest tales in the history of medicine is the story of the archetypal “wounded healer,” Chiron. As legend goes, Chiron, an immortal centaur, who both taught medicine and served as a physician, attended a gathering hosted by another centaur named Pholus. After a series of events involving other centaurs fighting over wine, Heracles (aka Hercules), in his attempt to intervene, accidentally unleashed a poisoned arrow that hit Chiron’s knee. Chiron, being immortal, was forced to endure unbearable pain.
Despite his ability to heal others, Chiron was unable to heal himself. Filled with shame, he retreated back to his cave, still committed to teaching his disciples. Eventually, after nine days, his pain became unbearable and Chiron requested that Zeus remove his immortality so he could die. Though a myth, it serves as the first documented story of a physician suicide, albeit assisted, and suggests that the challenge of healing our healers stretches back centuries.
The recent suicide of Lorna Breen, an accomplished and compassionate physician, researcher, colleague, friend, sister and daughter, after she served on the front lines of a busy New York City emergency department, reminds us that the plague of COVID-19 also creates deep emotional wounds in health care workers. As her father Philip Breen described her, she“was like the fireman who runs into the burning building to save another life and doesn’t regard anything about herself.” Her death was not due to COVID-19; it was due to a system and culture of hospital medicine that failed to value her as a human beyond her profession.
Right now, COVID-19 is a stress test, exposing the vulnerabilities in our financial, social welfare and health care systems. But it’s also a catalyst, giving rise to novel solutions such as providing a guaranteed basic income, expanding blood donation eligibility, reducing bureaucracy in hospitals and encouraging partnerships between tech companies. As such, it must also be a catalyst for improving medical culture so that one day no physician is forced to choose suicide as a result of an inability to cope or seek healing for themselves.
Awareness of the suicide epidemic plaguing the profession has gained ground over the last five years. Doctors have the highest suicide rate of any profession: about 300 doctors die each year in the United States (the size of a typical medical school student body). Effectively, suicide has now become an occupational hazard of the profession. But it’s also the canary in a coal mine serving as a warning for an overwhelmed and unhealthy system, one that doesn’t care for its doctors.
One thing is painfully clear: physician suicide isn’t about resilience. Doctors by definition are resilient; we must be to jump through many hoops to gain admission, serve on long overnight calls often without food, water or sleep, and work unreasonable work hours, often with an inadequate support system. Sadly the overemphasis on individual resilience at the expense of ensuring the work environment is healthy has placed the onus on doctors themselves—which is nothing more than victim-blaming.
While substance use and mental illness may be factors, many doctors do not have a diagnosed mental health disorder like depression and anxiety. This may, in part, be due to stigma around seeking a formal diagnosis, but we also know that symptoms of depression are wildly dependent on the environment; the influence of our situation on our reactions has been understood by sociologists for decades.
While things like mindfulness help to a degree, it’s a lot like expecting a soldier to meditate while bombs are being dropped all around her. The priority must instead be to get that soldier into a safe space with a battalion she can rely on, with the appropriate protective gear. Putting an otherwise healthy person, someone who is driven, intelligent, empathetic, in an environment that is not conducive to her well-being will place additional pressures on her with little room to thrive, or possibly even survive. The consequences can be disastrous, but are not surprising.
The problem of physician suicide is so deep, and the role of culture so paramount, that pontificating on solutions often feels futile, especially as the issue isn’t so much what the solutions are, but how to actualize them.
Culture must change from the top down, and this takes sound policies and commitment. Policies must include limits on work hours, time for self-care, and zero tolerance for bullying and harassment. We must also increase psychological safety (defined by Harvard scholar Amy Edmondson as “a climate in which people are comfortable expressing and being themselves”), a matter that is a pressing issue during the pandemic, as with the firing of doctors in Mississippi who have voiced concerns.
We should also ensure that all physician health programs are free of conflict of interest, completely divorced from licensing bodies, and accessible both geographically and financially. During a crisis especially, as we know from humanitarian aid workers, reentry trauma is common, and so access to these programs now is paramount in order to offset the risk of suffering alone. Isolation is an unsafe breeding ground for trauma, anxiety, and unprocessed grief.
Beyond telling the story of Chiron’s death, the ancient Greeks came to see suicide as primarily due to malfunctional “humors”—the end result of the build-up of black bile (melancholia) or yellow bile (mania). The beauty of medical knowledge is that it evolves; so too must our understanding. We must take lessons from as far back as Chiron, and as recently as Lorna Breen, to understand that environmental factors matter much more than the individual. Breen’s passing during this pandemic offers us a moment to reflect on how best to use our outrage and mourning, as patients and physicians, to finally move out of the clouds of ignorance, willful blindness and institutional inertia to prevent the same tragedy for repeating itself.
Once Chiron died, he left two legacies. The first was in those he taught: like the father of medicine, Asclepius, who in turn was said to have taught Hippocrates. Thousands of medical students take the Hippocratic oath each year. The second legacy, according to the poet Ovid, was through a gift from Zeus, who wanted to ensure Chiron’s spirit lived on in the night sky, so he created the constellation Centaurus—what may now be viewed a literal interpretation of the saying per aspera ad astra (“through hardship, to the stars”).
It shines brightest during the month of May. This year it might remind us of the thousands of physicians who took their own lives while healing others—some during this pandemic—doctors who might inspire us to finally change direction. And for Breen, as one of those bright stars, may we also vow to honor you as the hero you were, illuminating our path forward.
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources. Here’s what you can do when a loved one is severely depressed. For physicians on the front lines expressing mental distress or suicidal thoughts, or who just wish to talk, call the Physician Support Line 1-888-409-0141, which is open 8am to 3am ET, seven days a week, and provides free and confidential support with a volunteer psychiatrist.
**Originally published in Scientific American**
The coronavirus pandemic will leave lasting emotional scars.
According to my mother, there are two unique forms of grief that everyone touched by war understands. There’s the grief associated with the loss of human life—through bombings and brutal combat, and through the disease that runs rampant when health care and all other social services are halted. Then there’s the grief associated with the loss of a life as we once knew it: loss of country, loss of employment, loss of identity as a “prewar person,” and the subsequent need to start over. The two run along together like two dark snakes intertwined.
When my mother and father moved to the United Kingdom from Sri Lanka, amid a civil war that would drag on for 26 years, they didn’t readily display their grief. My siblings were born into the only reality we would ever know: visiting ducks at the local park, swinging on our neighbors’ swing set, and blowing out candles at birthday parties that were evidence of both assimilation and normalcy. Yet my parents’ grief would peek through at moments. The first time I ever saw my mother sob was the day she received a phone call with news that my uncle back home had lost his foot in a land-mine explosion. Years after we had moved to Canada, she learned that a famous library holding thousands of historical texts in her native Jaffna had been burned to the ground by the army. Her silent tears and the way she stared off into space, I realized then, were two more dialects of grief.
That kind of sorrow is unfamiliar to many people who live in peaceful places. Yet COVID-19 will leave behind a complicated form of grief that will linger—potentially for many years after the immediate crisis has abated. Thousands of bodies have piled up in Italy, during a period when doctors wrestled with horrific ethical quandaries around rationing care. Now, in parts of the United States, refrigerated trucks have been deployed for use as makeshift morgues. In New York, a mass grave is being built, and cremations are happening all day long. Patients are dying alone, and much like during the Ebola crisis in West Africa, fears of contagion have interfered with families’ ability to mourn.
As of yesterday afternoon, more than 20,000 Americans had died of the new coronavirus. The growth in the number of cases, fortunately, appears to be slowing. Still, even relatively optimistic projections indicate that many more people will succumb in coming weeks; even some who recover will still be at risk of long-term health complications.
All of this damage is occurring while people are still dying from other causes, too—and when grieving people are being discouraged from even going outside, much less seeking solace from their loved ones. Making matters worse, the current crisis has put enormous stress on the healing professions that, in normal times, help families deal with loss and bereavement. Our society is ill-prepared for the kind of grief the coronavirus is visiting upon so many people during so short a span.
Research on grief after large-scale casualties is scant, but the literature suggests that suffering personal losses can be particularly harmful when experienced in times of broader social stress. A 2015 study found that children who lost a loved one during a mass-trauma event such as a natural disaster, a terrorist attack, or a war are likely to suffer long-term psychological trouble. Studies of service members and veterans who served during 9/11 found a high prevalence of what is sometimes called complicated grief—a type of bereavement that is unusually severe and long-lasting. These service members and veterans showed worse symptoms of post-traumatic stress disorder and had a higher number of lifetime suicide attempts.
A study of survivors of the Rwandan genocide found that what the researcher called “unprocessed mourning”—in part the result of the halting of traditional mourning rituals during the war—contributed to lingering mental-health woes. Two years after the 2004 Indian Ocean tsunami, chronic grief was found in almost half the survivors, and was strongly associated with losing a spouse or being female. And a systematic review of Ebola survivors found high levels of psychological distress, including prolonged grief, which was compounded by the stigma placed both on survivors and their families as they attempted to return to work.
The coronavirus pandemic differs from those catastrophes in various ways. But it brings stressors of its own. Especially for those worried about vulnerable elders, it brings a level of anticipatory grief, the form that appears when the death of a loved one appears inevitable. It also comes amid a sudden economic crisis and skyrocketing unemployment; the disconnection of people from their families, friends, and their usual routines; and the recognition that some of those routines will be permanently disrupted.
In her 1939 short story Pale Horse, Pale Rider, the writer Katherine Anne Porter describes the protagonist, Miranda, as she falls in love with a soldier named Adam while also falling ill with the 1918 influenza. Amid their fear of the disease, the pair also grieve their old way of life. “All the theatres and nearly all the shops and restaurants are closed,” Adam laments, “and the streets have been full of funerals all day and ambulances all night.” Only when Miranda recovers herself can she fully appreciate the world she and her lover have lost. And when she learns, by letter, that her lover has died from the disease, she descends into the darker depths of prolonged grief.
“At once he was there beside her, invisible but urgently present, a ghost more alive than she was, the last intolerable cheat of her heart; for knowing it was false she still clung to the lie, the unpardonable lie of her bitter desire.”
The Diagnostic and Statistical Manual of Mental Disorders defines prolonged grief disorder as grief symptoms persisting for six months or longer after a loss, along with separation distress, impaired social or occupational functioning, and the presence of symptoms such as confusion, shock, bitterness, and difficulty moving forward with life. As the public sits in anxiety and in isolation, policy makers seeking to cope with the current crisis must also begin to plan for the demands on mental-health services, specifically for grief and bereavement, in the near term and beyond.
As a physician who is also the child of two physicians, I worry in particular about the grief experienced by the health-care providers who are making good on their ethical duty to serve those suffering from the coronavirus. After the 2004 tsunami, prolonged grief disorder was found in one in 10 hospital workers surveyed. In the current crisis, medical providers—including my mother, an anesthesiologist who performs intubations—are at personal risk. Even those who survive COVID-19 or do not contract it in the first place may lose valued friends and colleagues, amid the deaths of other health-care workers who have had to work without adequate protective gear.
In the hospital, doctors and patients alike have reasons to grieve. Doctors grieve the loss of a patient who has died. Patients, once a disease is diagnosed, grieve the loss of their health. Medical trainees grieve their former idealistic self as they become inured to a system that, ironically, often places little value on their own well-being.
Before the coronavirus, the ethos of humanism—of listening closely to patients’ concerns and fears and tending to their needs—had never been stronger in the medical profession. The pandemic returns doctors to a time when compartmentalizing a patient’s suffering—and one’s own—is an emotional survival tool. “We’re asked to be as dispassionate as the disease itself,” Daniel Lakoff, an emergency-room doctor in New York City, recently told me. “We don’t touch the patient in many cases, we use telemedicine, we give oxygen, and we watch and wait. And we often feel powerless.”
Claire Bidwell Smith, a counselor in Charleston, South Carolina, who has written three books on grief, told me that these recent weeks have been the busiest of her decade-long career. (She offers her services online.) She raises the possibility that grief may play out differently during this pandemic from how most people typically experience it. Usually grief feels very personal, Smith says, because the rest of the world proceeds normally while the bereaved feels numb and alone. That dynamic may change because much of the world has now ground to a halt. Grief may be delayed, she said, but a shared catharsis may lie ahead. “I think there will be a massive collective mourning when we’ve emerged from this, for us as a culture,” Smith said. “While what’s happening is heartbreaking, and we haven’t been able to ritualize or memorialize. We will come back to this.”
When I was growing up, another way in which grief visited our home was when my parents’ friends and extended family from Sri Lanka would stop by and reminisce. They would briefly recall the war but also use it as a frame in which to tell more uplifting stories of laughter and overcoming. Grief, when these adults experienced it together, became a connecting agent, joining the broken pieces into a more harmonious common mosaic.
The scars always remain. At the end of Pale Horse, Pale Rider, months of hardship give way to a future that is both brighter and tinged with melancholy. “No more war, no more plague,” she writes, “only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold light of tomorrow. Now there would be time for everything.”
**Originally published in The Atlantic**
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.
Sophia Bush is an American actress, activist, and entrepreneur. She is a member of the Directors Guild of America and has starred in various independent projects, shows, and movies such as John Tucker Must Die, Incredibles 2, One Tree Hill, Dick Wolf’s Chicago PD, and This is Us and has joined the cast of the upcoming show Love, Victor. Bush also co-founded and sits on the board for the public awareness campaign “I am a voter,” which promotes awareness of registration tools and encourages all to use their resources to participate in the voting process. Most recently, Bush launched a podcast, Work in Progress, which features frank conversations with people who inspire her about how they’ve gotten to where they are.
We spoke to Bush about how her normally busy life has been changed by the impact of COVID-19 and why she’s learning to not expect too much from herself while staying home.
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?
I’ve always struggled with routine since on set there is no such thing. Some days I have a 4:15 a.m. call time, and some days I go to work at 6 p.m. and film until the next day at 8 a.m. So I think I’ve always been enamored with people’s routines and looked at them with total fascination. In recent years, I’ve really tried to examine how to create routine.
Read more at MindBodyGreen.
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.
Rachel Pearson, M.D., Ph.D., is a hospital pediatrician and assistant professor of medical humanities in San Antonio, Texas. Through the Center for Medical Humanities and Ethics, she runs the website known as “Pan Pals,” which uses the humanities and allied disciplines to help preserve compassion, justice, and humanitarian values through and beyond the pandemic.
When we spoke to Pearson, she explained the way that her life as a doctor, a medical ethicist, and a newly expectant mother has been affected by the COVID-19 outbreak:
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 settling into a new job in a new city, and I had just found out that I was pregnant for the first time. I had made some friends, and one of my most important ways of caring for myself was going for walks in the evenings with a girlfriend. I would meet my friend Christy halfway between our houses, and we’d walk around the neighborhood with her two dogs.
In the hospital, one of the big joys of my new job was finding that I had lots of time to spend with my patients and their families, as well as with my residents. I could go from room to room in the afternoons and just sit down and check in with worried parents and sick kids. The human connection that comes from that time, as well as the knowledge that I was getting to practice medicine in a way I believe in, gave me a lot of peace and brought a lot of meaning into my life. I also knew that, with my own kid on the way, I would soon have a reason to want to leave the hospital as soon as possible—so, I was really relishing that deep time with my patients and families.
Read more on MindBodyGreen.