Show Notes: Dr Allan Detsky - The Subtle Art Of Ending A Pandemic

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Show Summary:

Dr Allan Detsky is the Professor of Health Policy, Management, and Evaluation at the University of Toronto and former Physician-in-Chief at Mount Sinai Hospital – and he was heavily involved in the health response to Ontario’s SARS outbreak in 2003. All of that means he’s seen the downsides of the psychological traps we fall into when we just want bad things to be over.

Show Notes:

  • [0:43] Dr. Detsky’s experience with SARS
  • [1:15] The infamous Metropole Hotel, Hong Kong
  • [3:58] Differences between COVID-19 and SARS
  • [9:28] The phrase Dr. Detsky wishes he’s had a nickel for every time he’s heard
  • [11:00] What’s going on in the United States right now
  • [12:03] Three common behaviors when people receive bad news
  • [14:27] Forbes article by Dr. Allan Detsky + Dr. Isaac Bogoch
  • [14:04] Thermometers and anxiety
  • [15:15] Our thirst for good news
  • [15:54] The importance of cognitive psychologists in government planning
  • [19:36] 25% skill + 75% luck in handling COVID-19 response
  • [20:47] The future + COVID-19

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Transcript:

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Show Notes: Dr Allan Detsky - The Subtle Art Of Ending A Pandemic

Jimmy
Dr. Allan Detsky is the professor of health policy management and evaluation at the University of Toronto, and former physician-in-chief at Mount Sinai Hospital and he was heavily involved in the health response to Ontario’s SARS outbreak in 2003. All of that means he’s seen the downsides of the psychological traps we fall into when we just want bad things to be over. I’m talking to him today about the subtle art of ending a pandemic. Dr. Detsky, thanks for joining us.

Allan
Thanks for having me, Jimmy.

Jimmy
Now, every virus is different. But COVID-19 must be giving you flashbacks to 2003 dealing with SARS. What was your role then? And were there any big lessons you took away from the experience?

Allan
In 2003, we had one of the few regional outbreaks of SARS which was a virus that originated in southern China, in that era, the virus was transported by a patient, man, who was a physician who went to Hong Kong and stayed at the famous Metropole Hotel on the 11th floor. And while staying there, he was what would be called a super spreader. So he spread the virus to many people who were also staying on the same floor and those people then flew to other places in the world. Toronto happened to be one of them. A woman returned from Hong Kong, she died in her home, her son became infected with SARS. He went into one of the hospitals in the east end of the city and the hospital was completely unsuspecting that this was the same virus that was occurring in southern China. He was a super spreader himself and he spread the virus to the many, many people in the hospital and healthcare workers and patients who then were transported to other facilities. And we had the beginning of our outbreak in several hospitals, ultimately 11 hospitals in the city of Toronto. My hospital was Mount Sinai Hospital. And at that time, I was the Physician-In-Chief. And so I was responsible for delivering clinical care, particularly the kind of care that would be used by patients infected with SARS. And so I was heavily involved in the planning of how we would deliver that care. In addition, we had a province-wide collaboration whereby every noon hour one physician from each hospital in one administrator got on a conference call, and we exchanged stories and I became the chair of that conference call, which ultimately ended up in producing a study that collected all of the cases in the Greater Toronto Area and summarise their clinical stories in a paper which we published. We were able to publish that paper fairly rapidly. And so in that capacity, I had a front row seat to what unfolded with SARS in the Greater Toronto Area.

Jimmy
And what is the difference right now, as far as we know, between SARS and COVID-19, is one is a lot more spreadable than others? And really what I’m asking is, SARS, in a lot of places, didn’t seem to be that big of a deal. For example, I was down in New Zealand and heard of it but didn’t really experience anything about it. How did SARS not become a huge deal like COVID-19 has become?

Allan
SARS was much more deadly. It had an overall 10% mortality, the overall case fatality rate for COVID, it’s not known yet, but it’s probably going to be somewhere around 1%. It’s certainly not going to be as high 10% and SARS was much less transmissible; it was primarily transmitted in hospital settings or healthcare settings. We use the term nosocomial infections meaning that patients and healthcare workers got SARS in hospitals and other similar health care facilities. But it didn’t have very much spread in the community. Unless a person was a super spreader, like, you know, Hong Kong and like that initial patient in Toronto. So it was easier to get rid of, because you could use traditional public health methods of case finding, contact tracing, and quarantining to get around the virus and it didn’t spread very quickly. This is a much more transmissible virus. Each person can probably transmit it to somewhere around two and a half other individuals. The patients when they get them are often not very sick so they don’t even know they have the disease. Whereas with SARS, if you got SARS, you knew it, it was easier to identify there was more fever associated with it. On the other hand, with SARS, we had no diagnostic test, with COVID we do have a diagnostic test, a polymerase chain reaction that tests for the actual RNA, the actual physical virus. The problem is that we don’t have enough testing equipment to go out and adequately test the populations at-risk or to do proper contact tracing. So it’s definitely a blessing to have the test. But it’s a bit of a curse, that in many countries, they don’t have enough swabs or enough re-agents to actually do as much testing as ought to happen. So those are the sort of things about the virus. From the community point of view during SARS, the hospitals looked very weird because when you came in, you got tested, your temperature checked and you wore an N-95 mask because it could be transmitted by airborne particles. And you wore that everywhere in the hospital and with every patient, every room that you went into you took all that off and put it on fresh and then took it off with each patient. So we were using protective equipment, like what you know, was like water. We had no worries about running out because there, we were the only city that was affected. And so the inside of the hospital looked quite weird. People were not allowed to collect, there was a lot of physical distancing, leadership teams had to separate because 12 hours later, they all went into quarantine. So hospitals looked weird, but the city looked normal. When you went outside, everybody was going about their business. Businesses didn’t close down, I went to family parties. I went to a bat mitzvah, I went to a Toronto Maple Leafs playoff game. The rest of the world looked normal. So that dichotomy or or stark contrast between in the hospital and out of the hospital was very striking. This is way different. In the hospital we’re not wearing N-95 masks, unless we’re doing aerosolized procedures. We are walking around and people can wear masks or not. They wear them obviously on patient units, or going into patient rooms. We’re not changing the mask with every contact with a patient. And the outside of the hospital looks very different than in SARS The streets are empty. People are where our physical distancing. People are staying home, businesses are closed. So it’s a very different feel. It’s the same phenomenon: a deadly virus, potentially deadly virus that’s travelling the world but the fact that this is much more transmissible and that it is many, many patients are so mildly ill they don’t even know they have us. That makes this far different.

Jimmy
And you talked about masks a little bit there, for example now in the hospitals that are using masks, is that because there’s not enough PPE, personal protective equipment, or is it for some other reason related to the virus?

Allan
Well, it, it’s both. SARS had the capability of being aerosolized. This is only aerosolized when we do a procedure on a patient like putting a tube down their throat, or cutting a hole in their throat, where they’re going to do a lot of coughing. We pretty much know that this is not, not something that’s transmitted by super spreaders, the way SARS was. So SARS was mostly not transmitted at all, except when it was transmittable and so because of the unpredictability of it, we had to wear the N-95 masks which are far more protective. And we had to change them with every patient which we still do when we are with COVID when we’re doing procedures on them. So we think this is much more droplet precautions, which means that the protective gear that you really need is a gown, a mask, gloves, and a face shield, a piece of plastic that covers over your face and covers the mask. And so the theory, and that it’s probably correct, because we haven’t seen lots of those nosocomial infections in Toronto, that you can keep the same mask on as long as you keep changing the shields. So that’s the theory behind the practice. But I’m sure that the truth is that if we had an unlimited number of masks, we would change them with every patient.

Jimmy
Just for risk management, right?

Allan
Here’s the phrase I’ve heard. I wish I had a nickel for every time I’ve heard this phrase in the last month… “out of an abundance of caution”. I don’t know whether they say that in Australia, but that’s a phrase for “I’m totally nervous and I’m going to do everything I can to not screw this up.”

Jimmy
And it seems like the mental state of people is really kind of communally in an abundance of caution right now. And obviously there’s there’s exceptions, but whether through a lack of understanding of the virus or through genuine concern, or realistic concern, people are taking precautions that may not have any relation to the danger that they’re in or the danger that the virus poses.

Allan
Well, I think in Canada as a whole, and particularly in Toronto, where I can see we’re taking this seriously, they’re not convening in groups, parks are empty. I think people are fairly adherent here and understand the dangers and not and I think that Canada is a bit like Australia, a bit like New Zealand. Sorry for insulting you. I know, Kiwis. I won’t get into that. But the mood here is people are understanding and are cautious and are careful. And they’re afraid and they see what’s going on in long term care facilities so they get it. The really weird thing because we’re so close to the American border is watching what’s going on in the United States, where there were a small minority is just completely batshit crazy demanding opening up protests. You know, part of that is speared on by right wing, ultra right wing media which is using this to promote its cause in some way. President Trump is participating in this in some way. But that’s always been true. There’s always been a segment of Americans who are exceedingly distrustful of government. I’m not placing a value judgement on that. But they’re behaving in a way that is quite reckless. And we’re watching that from across the border. I think it’s kind of sad to see that in the United States that they can’t get their act together to be able to control behaviour. But you know what, that’s what you get when you live in a democracy.

Jimmy
Indeed, indeed. And speaking of behaviours, you recently wrote an article talking about three common behaviours that you see often when people are receiving bad news. So whether it’s “you have cancer” bad news, or “the entire world is now in a pandemic” bad news. So can you talk about what those three behaviours are.

Allan
Well, the first behaviour is denial. When people are presented with overwhelmingly bad news, they don’t, they are unable to hear it, whether they’re presented with news that they have cancer, they can’t hear that they don’t even use the word cancer, they call it growth or something else. And so when we saw this happening in China, that’s far away, it’s not really happening here. We saw it happen in Iran. Oh, there’s no news from Iran. And you know, what does that look like? We saw it happening in Italy. Well, you know, maybe they are an older population, or they are closer, they do a lot of kissing. We don’t do that in Ontario, or in Canada. And so the farther away, the more remote away it was, the easier it was to deny that it was happening. The same thing was true in SARS, when we saw people dying of viral pneumonia in Hong Kong in China. We said, oh, maybe they don’t know how to treat viral pneumonia in Hong Kong in China, which is of course ridiculous. Of course they do. So denial is an important mechanism. So the second thing that people do and I definitely learned to recognise in myself is when they are faced with overwhelmingly bad news. They can’t deal with that. So they try to deal with what they can deal with. So the example that I gave in the paper was that family members of dying patients, instead of being able to absorb the horror of it, will ask about minutia. So they’ll, they’ll ask me as the physician, you know, I’m saying, you know, it’s not doing very well today and things are progressing. And they’ll say, okay, but yesterday, you told us his potassium was 3.4, which is slightly normal. Is it normal today, and I’m always astounded when I get that kind of question, even though I know what it means, because that’s something they can control. They can get the potassium to feel normal and they feel better for a few minutes. During SARS, I found myself repeatedly measuring my temperature when I would get anxious, and it would be normal and then I put the thermometer away and it would relieve the anxiety for about three minutes, and then I’d be measuring my temperature again. So I started to recognise that as an unhelpful behaviour in trying to control my environment to some extent, Isaac Bogoch, I wrote a paper that came out in Forbes as well about masks. I think that’s what masks is really about, is somewhat protective of you from other people. And it somewhat protects other people from you in a small way, especially if you learn to wear them properly. But what it really does is it gives people a psychological sense of control, like they have a barrier between them, and any person that might come within six feet of them and that makes them feel better. So that’s another behaviour, is attempting to control what you can control in your environment to relieve your anxiety. It works temporarily and once you learn to recognise that in yourself, you realise, okay, I don’t have to… I don’t have to keep measuring my temperature because it really is making me feel better. I might as well just be anxious. And the third behaviour is what we call the bias or thirst for good news. Everybody wants ours to be over. We ended our surveillance in Toronto, a little early, there was one little cluster of cases in the north of the city that we knew about. But we know that can’t be SARS doesn’t look like SARS. Let’s just… it’s over. It’s over. It’s over. And we opened up. And of course, we had another small outbreak, which fortunately we’re able to control. I can see that now. I mean, part of a protest in the United States is this is the thirst for good news. People would like this to just be over. The hazard is that that’s a bias. That’s the way the brain works. There’s nothing wrong with it. It’s normal behaviour. But you have to watch for that. And one of the things we recommended was that public health teams that are making policy decisions, might want to have a cognitive psychologist, listen in on the calls, to examine the data and tell people you know, you and you are interpreting that as good news because you want it to be good news. It really isn’t good news. Look at it more carefully, and maybe people will listen, maybe people won’t, but I’m quite certain that particularly in areas of the United States, I can see it already in the news tonight, they’re going to open up too early and there will be consequences for that. That’s life.

Jimmy
And from an evolutionary sense, obviously, these three behaviours are happening for a reason. We’re trying to calm ourselves, we’re trying to maintain hope. That’s how we deal with the world. But they lead to negative outcomes. So what sort of psychological reactions or behaviours are actually productive? And these sort of moments, what can we set as a goal?

Allan
I would say that when decisions are being made, it’s important to have multiple points of view, to not always have people in the room who are homogeneous with respect to their backgrounds or the way they see data. If everybody and certainly not having leaders who only will accept information that is the news they want to hear is a recipe for disaster in this kind of setting, so having multiple points of view, multi disciplinary points of view, people who could look at data objectively and it can interpret it properly. And maybe having, as I said before, I’ve been calling him a psychologist, asking the person, are you seeing that? Or are you or do you just want to see that? That would be important, but you know, at the end of the day, public health decisions and public policy decisions have to be made. They are binary decisions, we’re going to do A or we’re going to do B. And we know and public health, you make a decision, do I quarantine this person or not? Today I was going to call with a company that was trying to decide when they screen patients, screens through their workers coming back into the workplace, should they exclude people with the temperature over 38? Should it be over 30, the over 30, we have to make a decision, it’s going to be one or the other. And we know that some of those decisions are going to be overly cautious. And some of those decisions are going to be wrong and lead to infection, that if you’ve been around as long as I had, you just know that you aren’t going to get it right. And like I said, at the end of the last statement, that’s life.

Jimmy
And how does the future look for a country like Canada? Or I guess, what’s the medium term plan? Because I’m very familiar with, for example, New Zealand, which is looking to eliminate the virus. Obviously, it has a lot of geographical advantages with that sort of strategy. and Canada, is it or at least Ontario with what you’re intimately familiar with, is it just flattening the curve or is it trying to extend the period where people are really vulnerable to the virus?

Allan
Well, the first thing we’re going to do is all get on a plane and fly to New Zealand [Jimmy laughs and says I don’t know, because I’m not the government, it would be a mistake for me to speak for the government. But I think the number one objective was to make sure that our acute care facilities didn’t get overwhelmed. And then we didn’t end up looking like New York or Milan or Wuhan. And we were we and we don’t, as of April the 20th, we do not look like Milan or Wuhan or, or New York City. And so in that regard, we can view what we’ve done so far in the first part of the pandemic reaction to be a success. I would argue that that’s maybe 25% skill, and 75% luck. I don’t think… it would be a mistake to attribute our lack of having hospitals overrun to the actions that we took, I think We were just lucky that it didn’t, didn’t play out that way here. Because the premier of our problems, in his infinite wisdom on the 12th of March stood up in front of the television cameras and the media and said, go on your holidays, go travel, go do what you’re going to do for a spring break and enjoy yourself. Now not that he is spurred not that he could have kept people from travelling, because he didn’t issue a fiat nor did people buy plane tickets because he told them to. But that was exactly the wrong message. So it would be very hard for me to attribute the lack of our hospitals being overrun to our government actions because they… it would be inconsistent with what they did. Having said that they do take the problem much more seriously now, but the horse was out of the barn already. So I would say it’s mostly lucky. So now what we’re looking at is, first of all, we really need to do a better job in our long term care facilities. I don’t know exactly what that’s going to look like but somebody’s going to develop a plan for that. And then we have to see if we can get if, as we see the number of hospitalizations, new hospitalizations and new cases falling, whether we can gradually release the people back into the economy. We will have some examples like we can see what happened in Taiwan, we could see what happened to South Korea. You can see what’s happening in Sweden, which took basically the UK approach of letting the virus go wild and develop herd immunity, which I think is not easy to do. The probable prevalence of previous infection in the population now probably isn’t more than two or 3%. Herd immunity is 50%. Think of how much hurt it would take to get from 3% to 50%. That’s just not a reasonable strategy. There’s hope for a vaccine but that’s way off in the future. There’s hope for medical therapies, I think aside from antibody injections using convalescence for patients who have recovered from COVID, and hopefully that their antibodies will help patients recover. I think that’s biologically plausible here. But the other therapies that I hear people talking about are to me shots in the dark. With viral illnesses it’s not easy to have medications that ameliorate viral illnesses - where we were very fortunate with a lot of diligence to develop a drug therapies for HIV. But that’s because HIV is a very simple virus. And we’ve developed antiviral strategies for hepatitis C, but that took decades to develop. So I don’t see us coming up with hydroxychloroquine as a cure, or disappear as a cure anytime soon. I do think the antibody, serum antibody injections might work. So we’re a long way from a drug treatment. We’re a long way from a vaccine and we’re going to be in, what we really need to do is ramp up our public health facilities so that we gather around cases and do case finding with testing and quarantining people. Public health, the old fashioned way, the way they did it in whatever century the plague took place. That’s what we’re going to be looking for for the next year plus. But that could work. I mean, we were able to do that in SARS. And that could actually give it a tolerable level. The most fortunate thing about this virus is it doesn’t seem to affect young children. Unlike influenza novel influenza viruses, which really do do a lot of damage to very young and very old. That doesn’t seem to be true with this. So school opening is not out of the question. It might look different. But I think the economy will gradually open up over the summer, and then we’ll see what happens. We’ll see whether there are second waves and third waves, you know, Singapore which thought they had a beat, didn’t. New Zealand thinks it has it beat but wait till all the Ontario residents fly on that plane that I’m chartering tonight and get there. So, I’m uncertain except that I think this is going to hang around for a while.

Jimmy
And just to really quickly drill down on that prediction. Do you see a lot of countries ending up doing sort of cycling, lockdowns or shelter in place? Do you think it will be monitoring the rate of infection and then ramping back up the restrictions if you see it getting out of hand and kind of continuing along that path until we get some sort of drug therapy, vaccine, or something similar?

Allan
Yes, I think that countries… we will, we will one way or another learn how to test people rapidly for the PCR. The antibody test is not going to be useful for identifying infection and it has its own problems in identifying immunity as well, which, which, which is another topic, but the PCR testing is a viable option, we will almost certainly ramp that up, we will almost certainly ramp up case-finding in public health. And that’s the way we’re going to be for the future. And if things get out of hand in a city or in a region, we will lock it down. And that’s, that will be what it looks like, until we find a vaccine. And the other dark news is, we don’t really have vaccines for Coronaviruses. They’re not that - it’s not like influenza, they’re not that easy to develop, we might get lucky and find one or if we might have a long time search for a vaccine for this virus. I’m neither hopeful or more, nor am I particularly predicting that we won’t find it. But that’s that’s a complete unknown.

Jimmy
Just add that unknown to the pile, I guess. That was Dr Allan Detsky, Professor of Health Policy, Management, and Evaluation at the University of Toronto, talking with us about his experience with the SARS pandemic and how we can avoid falling into psychological traps.

You can find the audio and show notes for this episode at minaalradio.com/detsky, that’s d-e-t-s-k-y.