Letter by Dr. Rakowski to Friends on Covid-19 (April 24)
Dear friends
Thanks for the kind feedback and information that you send along
The good news:
We clearly have done better than most countries in dealing with the pandemic and are in the flat or descending limb of the curve.
Hospital PPE supplies are adequate with more supplies coming in but are still being rationed
Testing levels are being ramped up but remain below what is needed. The Spartan rapid test kit has been slow to implement at most sites. A major limitation is the number of swab kits available for nasal and throat testing. A saliva test shown to be accurate in small studies has received emergency regulatory approval in the US and would be a major breakthrough but not widely available.
Research is being accelerated and will yield ways to fight the infection. We just have anecdotal data yet which while encouraging isn’t enough for mass decision making.
There are some regions of the Canada that have low disease burden such as the Maritimes and Saskatchewan and Manitoba. This may allow earlier stages return to work for some businesses.
There is Ontario data on mortality rates for COVID-19 infected patients by age only and doesn’t include other risk factors such as obesity hypertension and Diabetes. There were no deaths in over 16,000 people under 30 !! The rate for ages 30-39 was 1/1000. It then increases linearly for each decade up to 60-69 at 2.4% but then is over 10% from 70-79 and about 20% over age 90. These rates likely overestimate death risk given a high number of asymptomatic people or those not tested and self isolated who recovered. The true denominator of those infected is critically important to predict true risk and allow us to triage those safer to work and those to continue isolation.
I have been pushing for more antibody testing in each of these messages and it is essential to understand how many people have unknowingly been infected and likely have immunity. It needs to be a more urgent priority. A New York study suggests that when the first case was diagnosed there were already 10,000 infected cases. As well antibody testing in NY showed a range of 3-21% of people tested had antibodies depending on their region. If the tests were accurate, which is not yet fully certain, this suggests a much lower rate of hospitalization and death than reported from clinically seen and admitted patients. If true and reproduced elsewhere it greatly increases the likelihood of relative immunity with greater safety to return to work in many more people. What remains unknown is the level of antibodies required for ongoing immunity and thus a truly free pass can not yet be given.
The bad news:
The LTC disaster is putting pressure on diverting testing and PPE to these terrible hot spots which may delay restarting other important care to some degree.
There is little antibody testing for potential immunity being done since seen as less of a priority than viral testing. This should be farmed out to the private sector with Public Health oversight for quality.
There are serious consequences to delaying important but not urgent care with deaths reported. Patients afraid to seek ER care for fear of infection are making the wrong and sometimes life threatening decision. Seek care if sick !! In the next few weeks there will be headlines detailing the harm done by restricting care even if the right decision. I feel strongly that it is no longer the right decision.
Outbreaks are reported in essential food processing plants highlighting risk of restarting the economy without some second wave and the need for careful worker safety precautions. Governments need to issue safety guidelines for workplaces with many workers and businesses and labour need to work together on compliance.
More and more financial support is being rolled out sometimes too slowly and often not enough but it has been very calming to those in need.
What comes next:
There is great tension between public health experts, the business sector, governments and individuals about when and how we can start easing restrictions safely. In the US this has sadly been politicized.
It is important to remember that different groups have different agendas and risks associated with guessing incorrectly. They also view the same data with a different lens depending on whether they are optimistic or pessimistic and their personal perspective and self interest.
What is apparent is the genuine concern that in Canada we do the right thing and that lives matter but there has to be a defined end in sight.
A senior government official may look at headlines wanting accountability for long term care facility deaths and fears the burden of blame for restarting life too early. In political life someone often has to be blamed whether at fault or a scapegoat. The press and the sometimes disloyal opposition may seek gain with shrieking headlines that display shock, often appropriate and sometimes with crocodile tears. No wonder they view the data conservatively.
The younger entrepreneur sees their dreams of a successful business vanishing as each helpless day follows the next. Will it ever end and how can I survive. Unleash me !! Even if I get infected I am unlikely to die. Just sequester those old people at risk.
The seasoned businessman says let me find a way to protect my workers on their early return or they won’t have a job or a decent life and my once solid business will be ruined as well.
This is the current tension when the printing presses are going as fast as they can. What discord will there be when the money runs out and we have to deal with the aftermath of at best a debt ridden economy in steep recession or possibly a prolonged depression.
Will a strong second wave bring social unrest, hunger, civil disobedience.
There are lessons to be learned in how to think and act when there is fear, uncertainty and even panic.
As the physician President of the American Society of Echocardiography 20 years ago I wrote an essay about lessons learned on how to deal with such anxiety and uncertainty in Medicine titled equanimitas, lessons from Osler.
Sir William Osler was one of the worlds most famous physicians. He was born in Canada and practiced here before founding Johns Hopkins Medical School in Baltimore. Emblazoned on the shield of their Department of Medicine is the word Aequanimitas the subject of an essay Osler wrote about the key quality of a great physician. It described coolness under pressure, projecting calmness to others, sensibility, clear judgement in times of crisis, and clarity of action during the storm.
Churchill possessed this during the war, speaking the truth and understanding the hardship of life but bringing comfort to those who he touched with the fiery optimism that we have it in us to persevere and overcome.
How do our government and business leaders, health care providers and we as citizens gain equanimitas so that we can carry on with dignity, hope and effective action.
Our leaders may be too slow for my liking in defining the logistics of safely getting back to work but eventually we will get there. We will also eventually have adequate public and commercial testing even if also too slow in being rolled out.
There is talk of perhaps restarting the economy on or before the May long weekend and we all hope this will be the case. To date we have relied on guidance and handouts from Government. In the next phase we each have to define the role we individually must play and the skills and determination we need to bring to a return to normalcy.
We will have to deal with the personal and economic aftermath of this disease that has almost crippled the world economy and created fear, frustration, anger and sometimes despair. What is therefore key, yet challenging, is for each of us to learn equanimitas.
The Medical Community:
We see exhausted Doctors and Nurses struggling through long days spilling into the night, fighting exhaustion and tears with sometimes inadequate protection and faces burned raw by their masks. They persevere they innovate, they risk their lives, they band together to find novel treatments because they refuse to give up or give in. Their administrators fight to plan and protect their patients and teams with encouragement and resources. Osler would be proud. Yet in the US some health care organizations are cutting Doctors and Nurses salaries to keep budgets stable. Most Canadian physicians sidelined from providing care are not being paid even though they do rebooking and administrative work. Not exactly a reward for heroic service. Stay cool, stay focused and continue to excel in doing your best and get help for the ensuing insomnia, nightmares and PTSD. Sir William Osler would be proud and so are we.
Medical Administration
While I think that we are being too timid in restarting regular care I understand the complexity of the moving parts and can only encourage taking that small risk as early as possible. The next second wave will be the death and disability of delayed care. Studies are being conducted to quantify the human costs of delayed care and it appears to be substantial. We are looking at our Innovation Committee funding a study quantitative this risk which can be used for second wave planning. We need to harness the large pool of data that needs to shared and will allow greater clarity for our future.
We thus need to put systems in place that better prepare for the second wave of both the virus and it’s collateral damage with greater clarity of risks, system needs and expectations of outcomes. We will continue to use virtual care when appropriate, triage the restarting of general care to those who need it most. We will innovate and increase efficiency to partially make up for shortages and unmet needs. Make no mistake, in the beginning it will not be enough and we will need to accept some delay and frustration.
We will need to reduce the inefficiency of drawn out process planning. An example is the recent rapid deployment in weeks of an electronic management system usually taking months to a year to implement.
Our Hospital health care administration has dealt with incredible complexity of planning and execution with grace under pressure an and unrelenting desire to do the right thing and keep us safe. Lets avoid some of the turf wars and lack of sharing of data at higher levels that have been reported.
What must government do:
Equanimitas for politicians involves being honest, transparent and resolute. Cynics argue that their prime directive is how do we win re-election and hide our faults while we make promises that we cant keep.
They by and large have stepped up their game in Canada. We have legitimate questioning of policy and timing but not of motive. We can agree to disagree without extreme polarization and hate that is so prevalent in the US whichever point of view you take. we can challenge the pace and quality of Government subsidies without being disloyal. We can reprimand politicians who have the right to criticize but not the right to be racist.
I hope they have the courage to make wise decisions that have risk but potentially greater societal benefit.
Death has been associated with our most vulnerable. We have universal health care but not universal opportunity for the poor and disadvantaged. Perhaps addressing this chronic and difficult challenge will take on greater meaning.
Our leaders need to redefine our relationship with China. We are the David to their Goliath but we know how that story can end.
They must have the courage to unite with other countries to say that what China as a state (not the Chinese people) has done is not acceptable and will not be tolerated.
In the Art of War Sun Tzu states what has become China’s state policy.
The whole secret lies in confusing the enemy, so that he cannot fathom our real intent.” –
We have allowed China to lie about the incidence and severity of disease to our detriment and punish the early whistle blowers.
We have abdicated to China almost exclusive production of vital supplies medicines and supply chains that put our economies and societies at risk to the whim of a regime that suppresses dissent and freedom and seeks domination.
We can no longer accept the wrongful imprisonment of our citizens, the theft of our intellectual property and the disinformation that is sown. We can’t even criticize China now for fear of restrictions of vital PPEs and supplies or the loss of a lucrative market.
England purchased 3,000,000 Chinese made care rapid test kits most of which are defective and inaccurate. Other countries including Canada have been similarly fooled with defective PPE. Yet China wants to be seen as a global saviour rather than to take responsibility for its causative mistakes.
It is important that we are not racist in this pursuit.
How did David defeat Goliath. What is their weakness. Ours is the need for cheap goods at any societal cost. China has an intelligent population yearning to be more free and an economy that is equally dependant on the need for foreign economies to feed their production capacity. Their weakness is having countries like Canada lead an international coalition of discontent to reward good behaviour and sanction bad behaviour. In the short term there will be some discomfort but in the long term they will hopefully behave with greater honesty and transparency or face the wrath of their trading partners.
Foreign aid and food aid.
Equanimitas means that our government should help third world countries that are at even greater risk of the pandemic. We have an abundance of food that can be purchased from farmers in need and an excess of oil. In time we can ship medical supplies and fund health care teams.
What industry must do
In the business world as in nature it is often the survival of the fittest. There are appropriate rewards for doing something better, faster, cheaper. Innovation is often disruptive and challenges old ways of practice bringing winners and losers. Creativity and constructive innovation is more essential now than ever and will come from the private sector not Government
In nature, when you starve with lions the lions starve last. Can we maintain effective business models that reward creativity and hard work yet bring a greater level of compassion, a sustainable safety net, less disparity of opportunity.
Will there only be budget and staff cuts to compensate for higher operating costs or will there be meaningful dialogue on ways to minimize disruption and not waste human capital.
Will banks continue to be kindler and gentler or foreclose too soon
Will we remember the beauty of clear non polluted skies or forget them.
Will teachers who were very opposed to greater e learning realize that this is what is sustaining education and Government remember how valuable essential education is.
Government and labour will need to work together for workplace safety. An outbreak will close a plant. There will need to be collaboration and mutual good will in dealing with the predictable and unknown challenges ahead.
Adi shared this interesting article on restating the economy.
https://www.bcg.com/publications/2020/restarting-the-economy-post-covid-19.aspx
So many of you have supported Hospitals, charities and those in need paying it forward with kindness and equanimitas. Below is a thank you for your kindness to my Hospital and their front line workers.
I am the Manager for the MSICU at TGH and on behalf of the entire MSICU community I would like to express our sincere gratitude for the food vouchers that you so generously provided. This acknowledgement is very meaningful for all team members particularly for our support services whose work often goes un-noticed but is vital to the safety of both patients and staff. Every day vouchers have been given to nurses, physicians, allied health practitioners (RTs, OTs, PTS, SLPs, dieticians) pharmacists, PCAs, clerks, ward aides, housekeepers, transportation staff, hemo nurses supporting dialysis in the ICU, and perfusionists helping to support ECLS. Hopefully I have not forgotten anyone. These vouchers have kept the team well-nourished and have definitely lifted everyone’s spirits.
Thank you does not seem to be enough.
With gratitude,
Denise
We will be at a critical crossroads as we recover from this pandemic.
We can choose the path that elbows out others for our share of scarcity or the path that makes us better and stronger. It is the steeper path, perhaps rockier and slower to climb but ultimately the better path.
My favourite poet Robert Frost wrote about the road not taken which I share below.
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,
And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
I hope that individually and as a society we choose the path to Osler’s equanimitas.
Stay safe and healthy
Dr. Harry Rakowski
Business Owner at range.promo
4 年Wonderful written . Thanks for sharing