An Opinion Pandemic

October 28, 2021/ by Amitha/ in Purpose/ Comments Off

Contrarian viewpoints on Covid-19 policy in mainstream opinion journalism risk provoking dire consequences.

Credit: Rawpixel

Over the span of four long days in September 1918, two leading voices expressed dismay about what was then known as the “Spanish Influenza.” First, Lieutenant Colonel Philip Doane, who led the Health and Sanitation Section of the Emergency Fleet Corporation, “forcefully” voiced that the Germans were behind the epidemic which had reached American shores earlier in the year, theorizing that German spies may have spilled the virus in a locale where a large number of Americans had gathered, such as a cinema.

“The Germans have started epidemics in Europe, and there is no reason why they should be particularly gentle with America,” Doane opined.

Then, a few days later, another opinion, by Surgeon General Rupert Blue of the Public Health Service, in an article in the editorial pages of the New York Times, downplayed the seriousness of the pandemic, suggesting that smallpox, dysentery, and typhoid were much more worrisome.

Doane’s statement further fueled stateside anger towards the Germans, but may have helped shore up support for the remaining battles occurring thousands of miles away. Blue’s words may have swayed public opinion towards not taking the pandemic seriously — and cases across the U.S. continued to rise.

For most of 1918, the coverage of the pandemic was dangerously slim, attributed in part to President Woodrow Wilson’s disinterest in addressing it. Most of the coverage in major papers was thus about the war, only occasionally punctuated with influenza death statistics.

But precisely a month after these opinions were aired, the Times changed tack, dedicating over 1,000 words in the Sunday editorial pages to the views of a recent Russian immigrant, a physician named Michael A. Iogolevitch, MD, who had both witnessed the epidemic first-hand in Europe weeks earlier, and served on the front lines during another flu epidemic 16 years prior.

Iogolevitch’s opinion was invaluable. For one, he argued that the term “Spanish flu” was incorrect, and that “pulmonary flu” was more appropriate. More importantly, he advocated for isolating infected cases, ventilation, and supportive care. He warned against transmission in children, and advised the appropriate use of medications. He also, humbly, lauded the efforts behind finding a vaccine while also emphasizing the need to educate the public about disease transmission:

“Thanks to the public health officials of this country, you appear to be on the eve of the practical application of a vaccine… I think your health authorities are on the right track… the public should be made acquainted with the disease through lectures, printed pamphlets, newspapers… in a short time the public may be taught the necessary fundamentals of the disease… such as not to cough or sneeze without a handkerchief.”

The Times appeared to heed his call to the key role newspapers play in impacting public understanding of the virus, increasing regular reporting of the pandemic such as the enforcement of fines to ensure public health guidelines were followed, and educating the public on the promise of vaccine research, all while warning them against ingesting “cures” that could “do more harm than good.” (La plus ca change!)

Portions of advertising space were also reallocated to public health messages that encouraged readers to wear masks and follow disinfection recommendations. That said, despite experts suggesting the pandemic had ended, and it was the time to reflect on learnings, transmission took a long time to curtail. After 50 million deaths, almost 700,000 of which were in the U.S., the last case was detected in April 1920.

Arguably, Iogolevitch’s views were influential in shaping how the Times and other newspapers reported on the pandemic, which then impacted public understanding and opinion, all of which collectively helped drive widespread behavior change. This illustrates that during a pandemic, it’s not just the reporting on the pandemic that matters; the opinions shared by experts also matter.

Over the last 18 months, with the influx of thousands of op-eds focused on the pandemic, we’ve seen the impact of airing contrarian opinions. In March 2020, a viral piece published by the Times, by David Katz, MD, a physician with expertise in nutrition, called for keeping businesses open.

A few days later, Trump used the same language from the piece to justify the administration’s inaction. As one journalist pointed out, this didn’t go unnoticed, suggesting that the op-ed may have, to some degree, either influenced Trump’s choices, or was used to justify his a priori plans.

One year later, an article in The Atlantic, by the economist Emily Oster, was similarly perplexing — another argument for a “laissez faire” approach to pandemic planning, this time applied to children. The blowback by infectious disease physicians and epidemiologists was huge, taking the form of an ad hoc scientific peer review over Twitter (as a disclosure, I consult for the Twitter health design team to support more productive disagreements on the platform), and while Oster issued a clarification on social media, the article itself still lacks a correction. It became weaponized by libertarians, and more recently, referenced in a testimony (and subsequent appeal) against mask mandates for children in Florida.

Then, earlier this month, another op-ed, by oncologist, Vinay Prasad, MD, MPH, called into question masks for children, only having been met by similar criticisms from epidemiologists and pediatricians. It appeared to be weaponized by anti-maskers and Governor DeSantis’ successful appeal may have benefited from this counterpoint narrative. While “children are not little adults” is an adage in pediatric medicine, which often applies to drug dosing, it doesn’t typically apply to standard practices like helmets, masks, seatbelts, and so forth — the potential trade-offs are usually worth it to prevent transmission at a time when pediatric cases, hospitalizations, and deaths are surging in this vulnerable unvaccinated group.

But the core issue here goes beyond any one self-described expert’s opinion. To make the criticisms solely personal is to fail to see the underlying problem. This dilemma has less to do with any specific individual, and more to do with the processes in place among newsrooms across the country to vet these opinions, including who deserves a platform (and who doesn’t), and whether the opinion offered is supported by sound data, all on top of the traditional challenges readers may face when discerning meaning from opinion journalism.

The idea to separate opinion from news was credited by the founder of the New York Tribune, Horace Greeley. Now there are codes of ethics for opinion journalism, and some newsrooms have their own. But this is complicated by the fact that most readers still have a hard time distinguishing between news and opinion, and efforts to label sections as “ideas” and “essays” may not always help with this distinction, particularly if they are written by an individual that “appears” to be an expert on pandemics.

At a time when editors may be burnt out, but when readers still expect quality data-informed advice, and where ad hoc scientific “peer review” on social media has limited impact (and fuels mob justice), we need a different approach, one that addresses two main problems. First, to what degree is expertise and credibility required when opining about an active pandemic, especially on policies by the CDC, and how best can editors determine this? Second, during an active pandemic, should the publication standards for pandemic-focused op-eds be higher, knowing that the consequences of readers integrating this information may be immense, potentially even impacting pandemic prediction models themselves?

The first issue involves expertise and credibility.

A common argument made by epidemiologists and infectious disease experts against the Oster, Prasad, and Katz op-eds are that they shouldn’t have been published because the writers lacked the specific expertise in the area they were commenting on. While this is an appropriate criticism
(we wouldn’t turn to an infectious disease expert to advise us on the economy of the country, the best chemotherapy protocol for a form of breast cancer, nor how national nutrition policy should be overhauled) it doesn’t heed the value of what “outsiders” — non-scientists and scientists alike — offer to the public conversation. Iogolevitch, despite being a physician, was an outsider by virtue of being a new immigrant who wielded no power compared to Surgeon General Blue or Lieutenant Colonel Doane. Moreover, we need only turn to Rachel Carson’s Silent Spring as self-evident. Carson was a citizen scientist, not an expert on environmental pollutants or human health, yet her outsider perspective helped shift public opinion, including that of countless scientists who resided in echo chambers, some who were unduly influenced by industry, and were altogether unable or unwilling to see their blind spots.

Echoing Thomas Kuhn, Carson spoke to the defining feature of science being that it evolves, including in her book an elegant quote from Johns Hopkins Professor Carl Swanson, that “others” are crucial to that evolution: “Science may be likened to a river… it gathers momentum with the work of many investigators and as it is fed by other streams of thought; it is deepened and broadened by the concepts and generalizations that are gradually evolved.”

As political science writer Philip Tetlock has written extensively about, experts are often blind to gaps in their understanding, which justifies why we need humble nonexperts in the room. As such, the downfall of many contrarian op-eds during this pandemic is at least in part due to a lack of intellectual humility; that is, the clear idea that their view is one of an outsider having appraised the evidence, but that the view is subject to change as understanding evolves. Indeed, if high quality traditional journalism is “balanced,” so too should opinion journalism be forceful yet flexible, especially so with opinions that run counter to established public health recommendations.

The second issue is whether an active pandemic necessarily raises the standards for pandemic-related opinion journalism.

This is specifically the case now where major news outlets are cosplaying as the main source of public health information, given the limitations on traditional authoritative bodies like the CDC. Compelling opinion journalism is supported by data and evidence. But who exactly is the judge of this evidence?

Unlike peer reviewed science, the judges, in this case editors, often do not have the deep expertise to scientifically appraise the quality of evidence used in an article; they can’t be expected to. Alas, that judgement rests primarily on the individual submitting their opinion, and their self-assessment of both expertise and ability to appropriately apply the data. The Katz op-ed was not buttressed by relevant scientific data, which was perhaps expected given that the pandemic was in its earliest weeks and such data was not available. As several infectious diseases experts pointed out, the Oster op-ed used sound economic modeling assumptions, but extrapolated these assumptions to epidemiological data (the crux of the concerns raised involved the conclusions perceived as erroneous). With the Prasad op-ed, as his critics pointed out, the overreliance on one small trial that wasn’t replicable and lacked external validity, rendered his main argument thorny. But what’s particularly puzzling with Prasad’s op-ed is that he co-wrote an excellent textbook that describes these very research limitations in compelling detail, and why they often lead to medical reversals.

To be clear, all three authors were likely well-intentioned in their efforts to provide a contrarian perspective; it’s the assessment of how these perspectives are weighed in mainstream media, during a time of immense uncertainty, that becomes a challenge.

A similar issue, around assessing expertise and the application of evidence, is present in the justice system with medical expert witnesses: Some states leave the judgement of medical expertise, and the application of scientific evidence, to a jury and judge who typically lack scientific training; others leave the determination to the expert’s professional peers who may be incentivized to support a colleague; both are imperfect.

During a pandemic, the stakes of misjudging expertise and the appropriate application of data, are high. One poorly supported opinion can be used to justify inaction or disobedience, which could then fuel higher transmission rates. Failing to have high standards effectively poses the same harm as the Tom Cotton op-ed controversy, but the consequences to flawed public understanding may be immediately dire and traceable, through the larger ripple effect on cases, hospitalizations, and deaths.

These two points — on expertise and standards — inevitably run up against arguments around free speech and censorship, which harkens back to another pressing issue in 1918, which was Wilson’s concern that contrarian opinions about the war, namely anti-war sentiment, could pose a risk to the populace. This led to the passing of the Sedition Act of 1918, which also covered which opinions would be voiced in the media (including newspaper editorial pages). The justification was that the common good of winning the war was held in higher esteem as compared to any individual’s right to protest against the war publicly. Seen as extreme, Associate Justice Oliver Wendell Holmes put forth a test the following year for assessing whether the Sedition Act could be applied, the “Clear and Present Danger Test” (bold emphasis mine):

“The question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent. It is a question of proximity and degree. When a nation is at war many things that might be said in time of peace are such a hindrance to its effort that their utterance will not be endured so long as men fight, and that no court could regard them as protected by any constitutional right.”

Notably, the Covid-19 pandemic has been likened to war by the very nature that it requires collective action and cooperation in order to defeat the enemy named SARS-CoV-2. Holmes’ attempt was to create a more objective way of measuring when free speech should be curtailed for the sake of the war, and more broadly for the public good. (Of note, libertarian sentiment against pandemic regulations was uncommon in 1918, possibly because the broader libertarian value around winning a war, and the associated freedoms, was perceived more salient.)

So how might we reconcile these two broad issues?

First, ideally, newsroom opinion sections should have at least one editor with scientific training and experience in critical appraising research studies to provide insight around whether a submission, regardless of the author’s titles, is supported with valid data. As this may prove difficult, investing in training opinion editors to be better judges can help fill in the gaps (trainings are offered by the National Association of Science Writers).

Second, creating a standard rubric for opinion editors to help assess a given “expert” op-ed would help — as a scientific peer reviewer, I’ve often followed these, which could be adapted for pandemic-focused op-eds. Included in such a rubric would be a variation of a “clear and present danger test”— applicable to potentially hateful views as much as those that could pose a public health risk. Third, newsrooms should regularly publish and make available, explainer guides to help educate readers on scientific media literacy. Fourth, where clarifications or corrections (or even a revision of a prior opinion) are offered by the writer, as with the Oster example, editors could publish this as an update to the article itself, though in much of these instances resorting instead to a newsletter may be better.

Fifth, whether it’s opinion or traditional journalism, caution should be heeded on any article that offers a crystal ball — whether around herd immunity, planning for social events next season, or when/how the pandemic will end.

At a time when readers are looking to news outlets for certainty, the temptation by newsrooms to provide this is strong. We don’t know how this pandemic will end, and no “expert” or conscientious science journalist, albeit well-meaning, knows either. Certainty remains elusive, and the most accurate pandemic forecasts are made a bit like the weather: a week or two at a time, a diminishing return on this accuracy the further out we go. The news media must continue to normalize this, as well as normalize that the understanding of SARS-CoV-2, as with all science, will evolve, so the recommendations and messaging will too (which doesn’t equal flip-flopping). Reporting that helps place the pandemic’s trajectory in context, and guide readers’ thinking will continue to prove extremely useful.

For readers who are turning to these pages for hope, but also prudent expert guidance, a healthy acceptance of the uncertainty that all of us — expert or not — are grappling with, as well as the limits of forecasting, will help undo some of the pressure many editors face to meet that need in their outlets. And of course, subscribe and support these outlets.

The original title of this essay was “What Silence Springs” (not very SEO friendly!) which is a play on words of Carson’s book title. That was intentional, to underscore a crucial last point. I’d be remiss to omit the fact that oftentimes the most knowledgeable and experienced people lack the platform to lend their expertise, or are implicitly (or explicitly) silenced, which is fertile ground for overconfident voices to take the lead. As with other professions, the journalism world struggles with a bias towards a certain “kind” of journalist or expert; my volunteer work mentoring several academics through The OpEd Project only further cemented that meritocracy remains an ideal. When it comes to opinion journalism, it’s on editors to ensure that it isn’t just the loudest often self-proclaiming experts who are provided with a platform for their views and ideas, but those with demonstrated expertise, humility, and thoughtfulness, as they often add immeasurable value to the public conversation — perhaps, especially, those voices that remain underrepresented primarily because they are excluded.

An outsider, but one who held herself to the same standards of scientific evidence as her more decorated academic contemporaries, Carson demonstrated that the evidence-based opinions of a nonexpert can indeed shift the public’s perception of the most pressing issues of our time.

She once proclaimed: “Wonder and humility are wholesome emotions, and they do not exist side by side with a lust for destruction.” Though Carson was referring to how humans experience our natural world, the same might be applied to opinion journalism. A reader’s sense of wonder is rooted in noticing how differently another might understand crucial issues; we are often humbled if that perspective is novel enough to change our minds. We also value that which is rare, which is why we pay attention to contrarian views.

But this wonder and humility, in its truest sense, cannot be derived from arguments that are ultimately destructive by virtue of being unsupported by the evidence.

During a pandemic which has now surpassed the death count of 1918, and where millions of citizens and their leaders base (or justify) their actions on what they read in newspapers they trust, it’s simply a pattern we cannot afford to repeat.

**Originally published in Elemental, and subsequently (slightly different version) in Poynter**

October Newsletter!

October 14, 2021/ by Amitha/ in Purpose/ Comments Off

October 2021

Welcome to the October 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.

Wiltshire, UK, Oct 2021

Some things that had me wondering this month:

1. COVID and…
The kids are alright: from The Washington Post, a story about a young boy not wanting to take his mask off for his school photo, and his sweet reason why!

A Canadian physician’s essay on caring for patients: and reflections on managing those who remain unvaccinated.

A great way to frame the pandemic trajectory ahead (without forecasting): From The Atlantic, 6 rules to help provide context ahead of the Fall/Winter.

2. Podcasts (& shows/books) worth listening to/watching
I loved this interview between psychiatrist Paul Conti and Tim Ferris on understanding trauma, the brain, and behavior.

And, in about 2 weeks in the US, Anil Seth’s book, Being You, will be released (it’s already out in the UK, a Sunday Times bestseller, and fascinating). I recently [and serendipitously] met Anil and had some of the most interesting chats in recent memory. His popular TedTalk is also worth a watch.

3.On…#Metoo, Consent, Desire, and so much more
By Philosophy Professor, Amia Srinivasan — her piece in the NYT was probably the most shared essay in my network last month. Her book of essays, The Right to Sex is also an excellent read.

4.Sound (and wise) reflections
And as part of the OpEd project, I coached Suparna Dutta and this is her first piece, on the butterfly effect impacting hospital transfers

5.Miscellany

The future of work is here.

If Canadian journalist, Sydney Page, who regularly writes for the “Inspired Life” column of the Washington Post, is not yet on your weekly reading list, she should be. This will make you cry (and hopefully smile too).

6.Best tweets of the month goes to…
Sahil Bloom, on what the Chinese bamboo can teach us about growth
Tareq Hadhad on the Canadian election
Elaine Welteroth, quoting part of Michaela Coel’s Emmy speech

Adam Grant, on reframing ‘self-worth’

Ted Lasso (which I just started watching!), on grief

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

As mentioned last month, I’m trying something new. 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 this small device — the Zulay frother. I love it for matcha, chai, coffee lattes for ambrosia-like froth, even for milk alternatives like oat or soy. It just makes the colder mornings (and frantic Sunday afternoons) a little more enjoyable.

Here it helped me create a fluffy chai (a ‘chuffy’?)

Chuffy!

In My Own Words…

For Elemental, I wrote about a topic I’ve been a bit obsessed with since February 2021: the sharing of opinions by ‘experts’ while a pandemic is underway. Poynter, which is a journalistic resource, ran a slightly different version as well. Writing wise, I just submitted my second round of book edits, and got assigned a really interesting magazine story, which brings me to London for a few weeks. The last ‘truly’ longform story I worked on was this one, so I’m eager to dig in.

Fly-fishing in West Chisenbury

I also caught my first ever fish (wild trout!), during my first ever fishing trip (in Wiltshire), with a very patient teacher (thanks RC!). It’s not trout season, so we put it back. But…’teach a woman to fish and she’ll smile for a lifetime?’ might be a great quote adaptation for these times. As well: I didn’t realize how meditative and relaxing fly fishing is…though…

If you have time this month, please consider donating to St Michael’s hospital foundation. A dear mentor (and a much-loved teacher of medical students and residents) from medical school, Dr Robert Sargeant, was diagnosed with an incurable form of brain cancer just over a year ago. I know that I still remain hopeful. Arguably Dr Sargeant was among the first people who turned me onto writing about medicine, with an essay he suggested we (our clerkship rotation group in general internal medicine) read: Letting Go by Atul Gawande.
It takes on special significance at this time.

Have a healthy, joyful, and safe October,

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

A lucky few seem ‘resistant’ to Covid-19. Scientists want to know why

October 1, 2021/ by Amitha/ in Nutrition/ Comments Off

Credit: Rawpixel

Her husband collapsed just before reaching the top of the stairs in their small one-bedroom house in São Paulo, Brazil. Frantic, Thais Andrade grabbed the portable pulse oximeter she had purchased after hearing that a low oxygen reading could be the first sign of the novel coronavirus. Erik’s reading was hovering eight points lower than it had that morning. He also looked feverish.

“When he hit 90% [on the oximeter], I said we can’t wait anymore,” Andrade recalled. “I called an ambulance.”

At the hospital that day in June 2020, a CT scan showed multiple lesions in her husband’s lungs — an indication of severe Covid-19 infection – which was later confirmed via a blood test. Erik, 44, had likely contracted the virus up to a week earlier, from a friend who had visited their home.

He spent the next several weeks on oxygen in the ICU, a stay that was complicated by blood clots before he was discharged. But it wasn’t his sudden decline and subsequent recovery that is notable: It’s that Andrade had been sharing the same close quarters with her husband while he was infected and able to transmit the virus. She never wore a mask in the home with him. They shared the same bed. They were physically intimate. Yet when tested for an active or past infection — twice — her bloodwork came up negative.

And that wasn’t the only time she was potentially exposed. As part of her research work as a veterinary neurologist, she went to a meeting at the University of São Paulo where an infected attendee set off a chain reaction of positivity – but Andrade dodged it. Her tests were again negative.

Both experiences suggest that Andrade may have won a sort of biological lottery — that she’s one of a lucky few “resistant” to the virus that has killed more than 4 million people. But how? That’s the mystery researchers around the world have set out to unravel.

The question of viral resistance has perplexed Mayana Zatz, a University of São Paulo genetics professor, for years, beginning with exploring the clinical variability of genetic diseases in patients who carried the same pathogenic mutation. She began with neuromuscular disorders like Duchenne muscular dystrophy, and then expanded to exploring why the Zika virus caused severe brain damage in some newborns while others were healthy.

In 2018, she published a study of nine sets of twins — seven fraternal and two identical — born to Zika-infected mothers; in each pair, one twin was born with microcephaly and developmental delay while the other was spared. Zatz suspected the answer to Zika resistance lay in their genes. To test this hypothesis, she collected blood from three of the pairs and reprogrammed their cells in the lab to generate induced pluripotent stem (iPS) cells and immature brain cells called neuroprogenitor cells (NPCs) that had genomes identical to those of the resistant and non-resistant infants. Then, her team infected the NPCs with Zika and found that the virus destroyed the NPCs of only those who were not resistant — supporting the idea that resistance is genetic.

It was a serendipitous moment in early February 2020, on her daily walk, that caused Zatz to turn her interest to exploring resistance to the Covid-19 virus.

Zatz often passed a middle-aged couple that lived nearby. After noticing the husband’s absence for several days, she stopped to ask after him. It turned out he had been gravely ill with Covid, yet his wife remained symptom-free. Zatz wondered: Along the same lines as the twin study, could discordant couples — where one is infected and the other not — be studied to potentially isolate gene associations for resistance?

Appearing on Brazilian TV a few days later, Zatz appealed for such couples to sign up for a study. “We received almost 3,000 emails of discordant couples, where one was infected and symptomatic while the partner was asymptomatic and seronegative,” Zatz told me.

After confirming the infection status of couples, her research team chose 100 of them to have their genes sequenced, in hopes of identifying mutations that are more frequent in key areas of the genomes of uninfected participants.

Zatz’s work is part of a growing effort to identify factors that may make people resistant to Covid, with the goal of finding clues to treatments, as well as understanding resistance against viruses more broadly. Other scientists have run lab experiments using CRISPR genome-editing technology to disable genes, in search of ones that could be manipulated to perhaps protect those of us not fortunate enough to have natural resistance against the coronavirus.

“The biological implications [of identifying a resistance gene] are important because it will provide one more piece in the assembly of the puzzle of the pathogenesis of Covid,” said pediatric immunologist Jean-Laurent Casanova of Rockefeller University, who has been studying the genes involved in Covid-19 severity, but is now shifting to look at elements of resistance. “Medically, if you knew you’re resistant, you know, you’d be relaxed. You would feel like King Kong right? The second possibility is that in people who are not genetically resistant, you can think of blocking the very same component on the surface of cells that you don’t have genetically.”

The first disease-resistance gene was discovered in 1905, when Cambridge University botanist Sir Rowland Biffen published a study isolating a single recessive gene for resistance to the fungus P. striiformis in wheat. The study has been pivotal in our understanding of genetically modified crops. A similar approach has since been applied to understanding children’s resistance to severe genetic diseases, and, more recently, to cancer. But when it comes to viruses, diseases that don’t arise within us but out of the environment and exposures, the picture becomes a bit more complex.

It’s hard to gauge how much you were exposed, and it’s not always clear when a virus makes someone sick. That’s especially true with SARS-CoV-2; the basic biology of how the virus attacks our bodies is still poorly understood, and its effects on people vary widely. Some people become infected but their immune systems spontaneously clear the virus, keeping them from developing the actual disease. These individuals may be asymptomatic, but this is not the same as resistance; an antibody test would generally detect evidence of a prior infection. Instead, resistance is broadly understood as having cleared a virus before it enters cells and gets a foothold – preventing infection, in other words, not just disease.

Resistance has been demonstrated against other viruses. In 1994, doctors found that a man named Stephen Crohn, despite having been exposed to numerous HIV-positive partners, was found to have no signs of HIV infection during multiple rounds of testing. Researchers later discovered he had a “delta 32” genetic mutation, which prevented HIV from entering his cells. However, later studies have suggested that resistance to HIV is rarely as simple as one mutation – there may be several genes and proteins that confer resistance, as found in research among sex workers in Kenya.

A team of scientists at New York University and the Icahn School of Medicine at Mount Sinai were the first to report finding genes possibly tied to resistance to Covid-19. In early 2020, Benjamin tenOever, a professor of microbiology at Mount Sinai, along with Neville Sanjana, an assistant professor of biology at NYU, and colleagues at the New York Genome Center set out to sort through the potential genetic factors underlying Covid resistance. To do this, they used CRISPR genome editing technology to disable each of the 20,000 human genes in lung cells and then exposed them to SARS-CoV-2. Most of the cells died within a few days. “Anything that lives,” tenOever explained, “is clearly missing something essential for a virus, and so potentially has a significant gene mutation.”

In January 2021, the group published a paper in Cell, reporting that RAB7A, a gene important for the movement of cargo from inside the cell to the cell surface, topped their quantitative ranking of genes the coronavirus can’t do without. Inhibiting RAB7A reduces SARS-CoV-2 infection by ensuring ACE2 receptors are retained inside the cell, making them unavailable as the required point of attachment for the spike protein of SARS-CoV-2 (which attaches and then enters the cell).

Although mutations in RAB7A are very rare, according to Sanjana, drugs that inhibit this gene or others required for viral infection could, in theory, be used as a treatment or even be used as a post-exposure prophylactic.

“Amazingly,” Sanjana said, “we found many genes whose loss reduces viral infection. For a subset of these, we identified existing drugs that can be repurposed to inhibit these genes. Some of them are already FDA-approved.”

But tenOever isn’t so sure their results will translate to therapies, noting that despite identifying the mutation that blocked HIV infection years ago, and spending billions of dollars since, we haven’t come up with a workable way to make people resistant to HIV. “Even if you found an inert protein that could be erased from our biology without major impact,” he said, “it doesn’t [necessarily] translate to any meaningful therapeutic.”

Casanova disagrees, believing that identifying mutations governing resistance can have a meaningful impact on therapeutics, but it involves re-imagining exactly where to target drugs.

In a paper accepted for publication in Nature Immunology, Casanova, Zatz, and colleagues with the COVID Human Genetic Effort propose several potential sites in the genome that could govern resistance to SARS-CoV-2, and suggested undertaking large genome-wide association studies that screen large populations for gene variants associated with resistance to SARS-CoV-2.

Casanova points to a limitation in the field of microbiology, which explains why therapeutics for infectious diseases have focused primarily on the disease-causing organism, instead of the host.

“The history of infectious diseases is essentially characterized by the idea that the microbe [alone] is causal, and you can prevent disease by vaccinating against the microbe, or by interfering with the microbe (via drugs). In my work, we see we can prevent or treat infectious diseases, not [just] by hammering the microbe, or playing with adaptive immunity (via vaccines or monoclonal antibodies), but by restoring deficient immunity, which accounts for life-threatening disease,” Casanova said.

This is the core reason why studying those who appear “resistant” to SARS-CoV-2 is of interest, he said.

This point underlies Zatz’s focus as well: In her Covid studies, she’s looking for mutations in genes that regulate the immune response to viruses. She hypothesized that two main biological pathways could be involved in resistance. The first is the major histocompatibility complex (MHC), which includes various genes that govern how the immune system recognizes and latches on to viral proteins. Another factor is the leukocyte receptor complex (LRC), which is involved in how various types of white blood cells – such as natural killer (NK) cells — respond to pathogens.

In April 2021 Zatz’s team published the initial results of the discordant couples study in a preprint posted to medRxiv. Contrary to the lab’s hypothesis, no single gene mutation in these pathways was responsible for Covid-19 resistance. In July, Zatz’s lab re-analyzed the results. Among the genes related to immune modulation, 46 variants in the MICA and MICB genes were associated with symptomatic infections, all which influenced NK cell activity in infected individuals but not in their resistant partners. Zatz found that NK activity was less efficient in symptomatic individuals. The resistant individuals were mostly women, with professions ranging from physicians to teachers to the trades. In other words: the ‘super-resisters’ could be anyone. This study has been peer-reviewed and is awaiting publication in the journal Frontiers in Immunology.

Overall, the findings echo that of the Kenyan sex worker study for HIV: Several gene mutations, working together, may confer resistance. Zatz hopes that this research, and the studies that follow, will shed light on future Covid treatments.

Her earlier Zika work, she says, illustrates how understanding resistance can lead to novel therapeutic approaches. Using the findings from the study of twins’ neuroprogenitor cells, and knowing that certain brain tumors of embryonic origin are largely comprised of the same NPCs, her team decided to test whether the Zika virus might be used to attack cancer cells. Hence a new experiment was born: Brain tumors in mice, “treated” with Zika, showed significant shrinkage — and in one-third, the cancer cells disappeared completely. When Zatz’s team repeated the experiment in dogs, the reduction in tumor size extended their lives for many months without side effects.

“Our enemy — the virus — became our ally,” Zatz said.

While Zatz and other researchers pursue ways to make all of us — as Casanova put it — feel like King Kong, Andrade doesn’t see herself as being endowed with superhuman abilities to combat the pandemic.

“It’s still not clear if I can spread Covid or carry the virus to someone, even though I am ‘resistant’ to it. Erik is clearly vulnerable, so it doesn’t feel like much of an advantage if my loved ones are not resistant,” Andrade wrote in an email. “And with new, more contagious variants complicating the slow rate of general population vaccination in Brazil, it’s really hard to be more relaxed about it.”

**Originally published in STATNews, August 2021**

September Newsletter!

September 15, 2021/ by Amitha/ in Nutrition/ Comments Off

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 E zra 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

September 6, 2021/ by Amitha/ in Nutrition/ Comments Off

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

Credit: Rawpixel

We rarely discuss ‘rest’ as a strategy for well-being.

However, over the last month, three professional athletes withdrew from major tournaments in order to prioritize rest for both their emotional and physical recovery, which has prompted some necessary conversation.

First, 23 year-old Naomi Osaka withdrew from the French Open (and later, Wimbledon), citing her mental health as the need to step away to recover. Then, 39-year-old Roger Federer announced he was stepping back from the French Open to give himself time to heal from a series of knee injuries. And most recently, Steph Curry, 33, of the Golden State Warriors made the surprising announcement that he wouldn’t be participating in the Tokyo Olympics, as he wanted to ‘focus on rest.’

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.

The idea that athletes specifically are subject to grueling schedules isn’t new.

In the world of professional sports, pushing through pain in order to participate in a game is commonplace. Injuries in recent years among athletes run the gamut: from the more notorious chronic traumatic encephalopathy to blood clots — both of which can be devastating for athletes’ health and can ultimately end careers. Just recently, after collapsing on the field, soccer star Christian Eriksen was diagnosed with an arrhythmia, requiring a defibrillator. In each of these examples, playing the sport itself contributed to poor health.

These themes are echoed in other industries too. Everyone from journalists to doctors cited burnout secondary to excessive demands during to the Covid-19 pandemic. Indeed, in Japan, the term “karoshi” (as in death due to overwork) is recognized as a healthcare problem.

Sleep itself, as I’ve written about before, has healing effects: everything from how quickly wounds heal to improving our mental health. But amount and quality of sleep can also impact how likely it is for athletes to get injured. A 2019 metanalysis of sleep loss and sports injuries in adolescents found that chronic sleep deprivation significantly increased the odds of injury, replicating findings from 2014.

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.

Grandner emphasizes that sleep is an active process. “The main job of the immune system is to regenerate every cell of the body, and that happens most often during sleep,” Grandner told me.

Last year, his team delineated the potential mechanisms of how sleep impacts recovery. One mechanism involves the mediating impact of sleep and decreases in inflammatory markers which affect the immune system and affect how well muscles are able to recover and repair damage from training and athletic performance.

Meeta Singh is a Detroit-based psychiatrist and sleep medicine specialist who advises several professional sports leagues such as the NBA and NFL. She underscores the element of circadian clock, and how restorative sleep allows injuries to be repaired more efficiently.

“If you don’t get enough sleep, you’re more likely to feel pain and the requirement for pain medication actually increases, so recovery and healing can be affected by this for instance because the higher need for medications can interrupt the healing process,” Singh told me.

Rest, however, must be distinguished from sleep in that ‘rest’ involves more generally taking a break from a specific form of ‘overuse.’ This can be physical overuse as seen often in athletes, or mental or emotional overuse. Each form of overuse may have factored into the decisions made by Osaka, Federer, and Curry.

Athletic performance can also be impacted by rest and sleep. In 2019, Grander’s team found that student athletes who were less sleep deprived performed better. Similar patterns were found in male division I college basketball: increasing their sleep duration to between 6.6 to 8.5 hours translated to a significant increase in free throw accuracy, and shaved up to 0.7 seconds off their sprint times. Knowing sleep schedules may even help predict NBA team performance: East coast teams typically lose when playing on the West coast due in part to the circadian rhythm impact.

In February, Singh’s team published a paper that assessed the role of sleep among players in the NBA, which was followed up by a commentary in April on sleep in professional sports in general, and another in June, about sleep in the NBA bubble. The consequence of poor quality sleep and insufficient (less than 7 hours’) sleep is clear: it negatively affects athletes’ mental and physical health, increases risk of injury, and decreases performance. The February paper cites Sacramento Kings assistant coach Jason March, in an interview where he shared: “You ask anybody in the room, the thing I talk about is sleep…I think in a couple of years [sleep deprivation] will be an issue that’s talked about, like the NFL with concussions.”

So why, with all the research we have around about the harms of not prioritizing rest and sleep to our brain, recovery, and performance, does it still seem shocking when an athlete announces they’ll be stepping back to rest?

We can look to the controversy around the NBA’s Do Not Play (DNP)-Rest strategy, which San Antonio Spurs head coach Gregg Popovich helped pioneer, for clues. The strategy prevents players from participating in too many back-to-back games, to allow for adequate recovery and decrease the likelihood of fatigue and injury. In 2012, Popovich sat Tim Duncan out for a rest day — this was his first implementation of DNP-Rest.

But a 2017 article in the Baltimore Sun, which pointed to the positive impact of the approach on both the Cleveland Cavaliers and Golden State Warriors, suggested that DNP-Rest enrages fans, who just want to see their favorite players play. In March 2017, Lebron James took a rest day against the Clippers. He came back rejuvenated, scoring 34 points against the Lakers. Fans of that game were impressed, but the ones who bought tickets to the Clippers game were angry at having paid for a ticket to a game where “the King” didn’t play.

Not every team institutes DNP-Rest — it’s dependent on the coach. Pat Riley of the Miami Heat once claimed: “We don’t rest. I don’t believe in it. I think it’s gotten to the point where it’s become a travesty, an absolute travesty. Blatantly. I don’t care how many players you’re resting or who. Who are the ones entitled to get the rest versus who doesn’t rest? We don’t rest.”

Does DNP-Rest work? While a 2017 study found that performance and injury risk remained unchanged, correlation data collected by teams suggests that the number of games missed by players due to injury or illness declined dramatically when the policy was instituted.

Uniquely, as the COVID pandemic forced NBA players to play in a “bubble” in the same time zone, with one Athletic Trainer noting “This is the advantage that we have not had. We’re always tired…[now] our guys have been rested. They’ve been fresh. We’ve been able to get them recovered again and again.”

In December 2020, Singh’s team looked at the impact of these player bubbles, and found that removing the element of travel during pre-season NBA games, among other things, was associated with an increase in shooting accuracy, though it’s unclear if this was secondary to less circadian rhythm disruption, or the negative impact of excessive travel more generally.

At some level national sports culture plays a role in normalizing rest for recovery. In North America, the “hero” ideal of self-sacrifice and pushing beyond one’s limits to achieve a goal is prized and fans pay a premium on sports tickets to watch “their” player play. However, in European soccer, fans tend to be more concerned about player health, pushing coaches to sit players out if they seem fatigued or suffer an injury. In other words: soccer fans prioritize the long-term health of their favorite players, so that they can have the pleasure of watching them over the years.

What this suggests is that prioritizing rest for recovery in professional sports is less about the type of sport and culture, and more about the type of fan, and whether fans, who drive the billion-dollar global industry of professional sports would be ok with delayed gratification (seeing their favorite player sit out) if it meant their favorite athlete had the opportunity to recover, and thus perform at their best.

The conversation around wellness more broadly has for years centered around trends such as biohacking: fueling an industry pegged at over 4.5 trillion dollars. Some of the innovations in ‘self-care’ are justified, and are backed by evidence. However, true well-being and healing may rely more often on “not” doing something — over-exerting, overperforming, and overworking — as opposed to “adding” another trendy “wellness” element to our routines. This new recognition may be reflected in the post-COVID movement towards prioritizing the balance of rest and work, reflected in many choosing to work from home.

Indeed, over this past month, Osaka (who recently penned an Op-ed), Federer and Curry have modelled the idea that stepping back to heal, even in the midst of external pressures to push through, while the tougher choice, is often the most crucial to optimize well-being and long-term performance. And when we all understand the difference between the physical and mental implications of choosing ‘grit’ when what we most need is ‘rest,’ if recovery and healing is our goal, we’ll all be better for it.

**Originally published in Elemental July 2021**

August Newsletter!

August 21, 2021/ by Amitha/ in Nutrition/ Comments Off

**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

August 16, 2021/ by Amitha/ in Nutrition/ Comments Off

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.

“My real concern isn’t the message but the messenger,” she responded. “I didn’t like how the experts on TV kept changing their minds about it, and the politics of the Covid response. But I listen to my doctors, and feel I can raise questions and they listen.” Over time, Diane’s trust in her doctor has grown; not long ago, she made an appointment to discuss a mole on her cheek, and it was identified as an early-stage cancer and removed.

A face-to-face relationship with a doctor is one thing, and a press conference on television is another. Usually, our health is a private matter. For the past year, though, we’ve been in a national—or perhaps even global—doctor-patient relationship. Hundreds of millions of us have watched in real time as health experts and politicians take in information, make up their minds, and sometimes change them.

Can trust in medicine be built en masse? As Diane’s story suggests, the medical profession at large has an opportunity, as the pandemic recedes, to reenvision the doctor-patient relationship. They flatten the hierarchy, create space for open conversations, where patients can voice their knowledge, allowing doctors to share their own humanity alongside the potential and limits of various medical treatments and physicians’ knowledge. A new approach that welcomes both the doctor and the patient in the same room could improve understanding and compassion, and ultimately lead to better care. If medicine moves forward through course corrections, it must take patients with it.

The Re-Emergence Effect

August 15, 2021/ by Amitha/ in Nutrition/ Comments Off

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.

A 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?

July 15, 2021/ by Amitha/ in Purpose/ Comments Off

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!

July 1, 2021/ by Amitha/ in Purpose/ Comments Off

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.

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