Friday, May 15, 2020

Thinking "broadly and deeply..." about COVID-19

That's a quote from my colleague, Dr. Ann Swartz, this morning in a series of group messages we share among our nursing faculty. It was a reference to an article she found, Dr. Peter Piot's interview in Science Magazine online. Piot, a virologist who studied AIDS and Ebola, says in the piece, "Finally, a virus got me." Piot suffered from COVID-19 in a hospital in Britain, and while he is better and recovering at home, he is not completely well. He, like many, was walking around with a low grade pneumonia, and low oxygen levels, until it became too much to bear, and he presented for treatment. You can read his description of the experience in the link above.

Also, this past week I posted on my Facebook page a brief piece on a newly emergent pediatric manifestation, "hyperinflammatory shock" is what the authors of this article in The Lancet call it. It seems some kids, eight patients in this report--most of them otherwise healthy, get a generalized inflammation that can appear like Kawasaki disease or toxic shock syndrome. The New York Times reported on cases in New York, where, at the time of their article, it had caused the deaths of three kids. It's serious. These kiddos need to be in ICU. It seems to be an immune hyper-reaction, maybe related to the "cytokine storm" we've seen in adults with COVID-19 pneumonia, just with a different presentation and timing.

With these developments, is it any wonder that many people want to maintain strict limitations on travel and activity?

So California State University announced closure of campuses in the fall--and we're months from that yet. Dr. Anthony Fauci, in Senate testimony warned that the Winter of 2020-21 could be "the darkest winter in modern history."

So it must seem incredibly rash to want to open our society again! Until one starts "thinking more broadly and deeply."

Julia Marcus, a professor of population medicine at Harvard, writes in The Atlantic that "Quarantine Fatigue Is Real" and argues for "harm reducation"--a long-known theory in addictions medicine that admits that 100% adherence to abstaining from drugs or alcohol or sex is not achievable, because we are human beings, not perfectly disciplined robots. During the pandemic, the message we get is that we must adhere 100% to staying at home, not touching anyone, and so on. A lot of us have been able to sustain that, for a time. But Marcus argues that most of us cannot sustain this behavior forever, and not even for many months on end.

Marcus observes that "pandemic shaming" has become a thing, with people shaming others online --often without full context--for appearing to behave in ways that some of us think are shameworthy. I concur. I've been seeing this online as well. Why aren't those people staying safe? What's wrong with them? This has morphed into Why aren't they protecting me?

Individuals are forming opinions about what they consider "good [pandemic] behavior" and bad. Many say they base their opinions on "science"--but that neglects the fact that even the scientists have a point of view, and unrestrained by the strict rules of scientific writing, those biases can inform their public pronouncements. When Fauci warns of "the darkest winter" the image is evocative, scary, and can influence people to do what he wants: limit disease spread, limit deaths, limit stress on hospitals, and therefore achieve one kind of "good." One can't say that limiting these bad things isn't good.

But are there other "goods" that we want, and other "bads" that we wish to avoid? Perhaps. Dr. Dimitiri Christakis, director of the Center for Child Health, Behavior and Development at Seattle Children's Hospital and the editor-in-chief of JAMA Pediatrics, argues that we need to start thinking about the mental health of children, and balance that with our efforts to mitigate coronavirus, in this article at NPR. Christakis argues that social development, mental health, risk for child abuse, and risk for hunger are all increasing as the lockdowns continue and the economy crashes.

The author of the NPR piece shares examples of children who are depressed, angry, irritable, and who are starting to say things like "I don't care if I die." If I was that parent, that would certainly freak me out.

As I said, I've been seeing this tug-of-war between people who argue that we must continue strict distancing, lockdowns, and school and business closures; and people who argue that all of this is an "overreaction" or that the virus "isn't that bad" or that the "cure is worse than the disease." This is entirely expected, as people en masse tend to dichotomize issues between extreme choices, but I am thinking that these extremes are a false choice. There are others.

I'm doing ok. As a professor, I still have a well-paying job. It's not that difficult for me and my wife, a musician, to stay at home on our lovely property and wait this out. In scanning my feed on social media, I have begun to note that many of the people who argue for continued strict isolation also have the good fortune of working in the knowledge economy where they can work from home. They're still employed...or retired and thus not in danger of losing their lifestyle.

I also notice that many of the people arguing for opening up faster are people who are furloughed or laid off entirely, their jobs never-to-return. Or they're students who face declining educational and social experiences, and future financial uncertainty as the lockdowns start to push into the fall (like this student suing my employer over the spring closure--I'm not sure I disagree with him).

As I thought about what I have been seeing, I began to see that strict lockdown may be a luxury for some, a curse for others, and the inflection point of that divide seems to me related to the balance between competing goods that are individually determined and individually focused. Put another way, rather than asking "what is good for all of us? (even if that comes with risks)" we seem to be asking "what is good for me and the people in my circle?"

I think this pandemic has become an unintended emblem for our times: us against them. The "us" and the "them" simply depends on one's point of view, but in the aggregate these tiny points of view coalesce into shapeless extremes.

Between March and May, the Earth caught fire--"corona" a crown of fire around the Sun--a very apt metaphor for how swiftly and terribly the virus has overtaken us. We have to control the fire, and little fires are probably going to burn on for many months or even years. But we can't let the fire completely overtake our common sense of humanity, and the many needs that humanity requires. We have to change the conversation from "this versus that" to how can we build toward the better things for all of us--even if they aren't individually the "best" things for each of us.

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