Thinking about mental errors

Don’t let mental errors cloud your thinking. Image by Jan Buchczik for The Atlantic

by George Taniwaki

Arthur Brooks is a conservative social scientist. He is on the faculty of Harvard Business School and was formerly president of the American Enterprise Institute. Since 2019, he has been writing a series of articles in The Atlantic, now called “How to Build a Life.” With the onset of the Covid-19 pandemic, the articles have included advice on how to live a a happier and better life by understanding our life circumstances.

In his Apr 23, 2020 article entitled “Two Errors Our Minds Make When Trying to Grasp the Pandemic”, he makes the case that we would be happier if we understood the difference between two experiences that make us unhappy and two conditions that make us nervous. It is a very thought provoking article and I highly recommend it.

Regret and disappointment

Regret and disappointment both lead to unhappiness. They seem similar but are not. We should only feel regret for bad decisions that we have made. Then we should work hard to develop strategies to do better next time. But we should not feel disappointment.

In contrast, we should only feel disappointment when we are in situations where we had no control, like the Covid-19 pandemic. And once we recognize we have no control, we should endeavor to stop our disappointment and get on with other thoughts that will make us happy. As Brooks says, “rumination on what you would be doing if it weren’t for the coronavirus is a destructive waste of your time.”

Risk and uncertainty

Most people dislike risk and uncertainty. Again, these conditions seem similar but are not. As Secretary of Defense Donald Rumsfeld famously stated, “There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.”

Risks can be thought of as the known unknowns. These are outcomes that we cannot accurately predict, but understand well enough that we can forecast them using stochastic models. We can also mitigate and manage risks by working hard using the appropriate strategies and interventions.

Uncertainty are the unknown unknowns. How many people will die from Covid-19? Is it safe to open schools in the fall? Will I or a family member get the disease? We don’t know and can’t predict these with the information currently available. That is, we as laypersons cannot convert uncertainty into risk. Thus, we should not spend a lot of time worrying about these questions. Doing so will exhaust us and make us unhappy without leading us to a better prediction.

Acknowledge, distinguish, resolve

Mr. Brooks has a three step solution to overcoming these two cognitive errors. He calls his solution “acknowledge, distinguish, resolve.” As he writes, “Disappointment and uncertainty are inevitable, but we don’t have to turn them into suffering.”

 

Redlining and Covid-19 risk

Valverde neighborhood has the highest rate of Covid-19 hospitalization in Denver. Image from Christie Mettenbrink for Denver Public Health

by George Taniwaki

Denver’s Valverde neighborhood is just a few miles from the Barnum West neighborhood where I grew up. The streets there are busier and noisier, with more industrial businesses lining Alameda Ave. and Federal Blvd. Studies show excessive car traffic can lead to stress and chronic respiratory ailments, especially when combined with smoking, which is more common among residents there.

The houses are smaller, with more families living in multigenerational arrangements. Residents are more likely to ride public transportation to get to work or school. They are also more likely to have jobs that are considered essential. Crowded living and working conditions increase the likelihood of contracting Covid-19.

Finally, adults in Valverde are less likely to speak English at home, meaning they have less access to healthcare information. They are less likely to have health insurance and less access to healthcare providers, even if they have insurance.

This isn’t an accident of history. Cities like Denver had long adopted policies (Colorado Trust, May 2018) that encouraged racial segregation and discrimination. From the 1920s until the 1970s, the city worked with banks, mortgage companies, and property insurers, to draw maps of neighborhoods that were safe, a practice called redlining. Similar maps were used by Denver Public Schools to plan the location of new buildings to ensure schools were kept racially segregated.

Even today, the impact of segregation is still visible. An excellent article in The Conversation (May 2020) looks at the distribution of Covid-19 hospitalization rates by neighborhood (see map at top). You can see more charts and an explanation at Denver Public Health (May 2020).

 

Happy birthday Florence Nightingale

Example of polar area chart showing causes of mortality among soldiers by month during Crimean war. Image from Wikimedia

by George Taniwaki

May 12 is International Nurses Day to recognize the contribution nurses make and to celebrate the birth of Florence Nightingale. Today marks the 200th anniversary of her birth. The World Health Organization named this year the Year of the nurse and midwife in her honor. Certainly, with the Covid-19 pandemic in full force, 2020 will be remembered as the Year of the nurse for many years to come.

Ms Nightingale, who was born in Florence, Italy was the founder of the modern nursing profession. Prior to her efforts, nursing was a volunteer activity, most often undertaken by untrained family members, soldiers, or religious members. Ms Nightingale trained nurses during the Crimean War. She later founded the first secular nursing school and published many nursing textbooks.

In addition to advancing nursing in a clinical setting, Ms Nightingale was a social activist who advocated for more government spending on healthcare for the poor. She helped develop the field of public health nursing to reach patients who were poor and sick at home.

Finally, Ms Nightingale was an incredible statistician and a pioneer in data visualization. She kept thorough notes and documented which treatments worked and which did not, making it possible for others to replicate her results. She popularized a type of pie chart that she called a coxcomb (see image above) and is now known as a polar area chart. She was the first woman elected to the Royal Statistical Society and became an honorary member of the American Statistical Association.

 

Washington state announces Safe Start plan

Washington will end its quarantine using a four-step plan. Image from WA governor office

by George Taniwaki

On May 4, the state of Washington announced a plan to end the quarantine (Medium May). The plan is called Safe Start and includes four phases. The state is currently in Phase 1.

For each later phase, the list of allowed social activities and businesses that can be open increases. The lists are a fascinating insight into the conflict between medical advice, business interests, and social pressures that have surfaced during the pandemic. For instance golfing is allowed during Phase 1, but social gatherings are not.

Flexibility at the county level

One of the problems that other states have had regarding social distancing compliance is that rural areas with smaller populations and lower population densities believe that quarantines are being imposed on them by big city politicians. Thus, any successful plan must include a method for them to open faster, if the medical conditions allow it. (That is, if the caseload is low enough to not overwhelm the local hospitals, testing levels and contact tracing efforts are high enough to catch nearly all cases, and social distancing and hygiene practices widespread enough to reduce infection rates.)

Washington’s plan allows counties with a population of less than 75,000 that have not had a new case of COVID-19 in the past three weeks to move into later phases earlier by petitioning the state Department of Health.

 

The man who saved the most lives in history

Maurice Hilleman (center, rear) talks with his research team as they study the flu virus in 1957. Photo by Ed Clark/The LIFE Picture Collection via Getty Images

by George Taniwaki

The fall 2019 issue of Univ Chicago Mag contains the incredible story of Maurice Hilleman, PhD’44, a microbiologist. I had never heard of him, but he is truly an unsung hero. He worked on 40 vaccines in his lifetime. In an obituary published upon his death in 2005, Mr Hilleman is credited with saving more lives than anyone else in medical or public health history. That praise comes from Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (Wash Post, Nov 2005).

Mr Hilleman was one of the discoverers of the two types of genetic changes (called shift and drift) that cause humans to get repeated infections of the flu. His work guides the selection of which flu viruses that should be included in the annual flu vaccine and to predict which flu strains are likely to cause a pandemic.

In 1957, he was one of the  first people to realize an emerging 1957 flu virus could become a pandemic and sweep across the world. However, neither the US Public Health Service nor the Influenza Commission took the threat seriously. Hilleman approached six vaccine manufacturers directly. Forty million doses of vaccines were prepared and distributed. Although 69,000 Americans died, the pandemic could have resulted in many more deaths. Hilleman was awarded the Distinguished Service Medal for his work.

In addition to flu vaccines, Mr Hilleman was involved in the creation of vaccines for measles, mumps, rubella (and the combined MMR vaccine), hepatitis B, and chicken pox (varicella). Overall, he worked on 40 vaccines, including 9 of the 14 diseases that now have pediatric vaccines.

 

The eradication of smallpox

The cow pock or the wonderful effects of the new inoculation! – the publication of ye Anti-Vaccine Society. Image from Wikimedia

by George Taniwaki

Today marks the 40th anniversary of eradication of smallpox. You probably don’t fear smallpox. That’s because it is believed to be the first, and so far only, infectious disease of humans to be eradicated.

About smallpox

It wasn’t that long ago that smallpox was the most feared disease on earth. The disease is highly contagious and has a mortality rate of 30%. It could make whole cities uninhabitable. Those who survived it may have had scarring and blindness. The origin of the smallpox virus (Orthopoxvirus variola) is unknown. Based on gene clock dating, it may have first appeared in Africa about 30,000 years ago after jumping from rodents.

The disease may be the source of many of the plagues that have been recorded in history and is estimated to have caused 300 million deaths in the 20th century alone.

Prevention

Long before the development of modern vaccines, people realized that taking the small bits of the scabs and pus from a person infected with smallpox and inhaling it could result in a milder form of the disease. The mortality rate for this inoculation therapy was about 2 to 3%, but many felt it was a reasonable risk during an epidemic outbreak.

In 1796, Edward Jenner noticed that dairy farmers were less likely to get infected by smallpox. He guessed correctly that inoculation with the scabs and pus from a person infected with the O. cowpox virus would confer immunity to smallpox . Cowpox is a milder disease than smallpox, so the mortality risk from inoculation was lower as well. The name of his invention, vaccine, is derived from the Latin root vacca for cow. Not everyone was enthusiastic about his invention and anti-vaccine societies took root (see image at top).

The current smallpox vaccine is based on a third virus, O. vaccinia, which is closely related to horsepox and is believed to cause an even milder disease. The vaccine is about 95% effective while causing side-effects in about 2% of patients.

Newer vaccines have also been developed but not deployed. One, based on O. vaccinia Ankara uses a version of the vaccinia virus that has been modified so that it does not replicate, so cannot cause disease. Another contains recombinant DNA that express genes for the antigens, so does not contain any virus and does not need live animal cultures to manufacture.

Eradication

In 1959, the World Health Organization (WHO) proposed a plan to eliminate smallpox. However, funding did not appear until 1967, with the launch of the  Intensified Eradication Program. Cases of smallpox dwindled and one at a time, continents were declared disease-free. The last known case of smallpox occurred in October 1977 and the WHO certified the global eradication of smallpox on May 8, 1980.

As the disease became eradicated in developed countries, it became clear that while the number of hospitalizations and deaths were zero, the injuries caused by side effects of the vaccine were quite high. Thus, all nations began eliminating vaccination of their populations for smallpox. The exception is the U.S. military, which vaccinates all service members.

Today, the biggest controversy surrounding smallpox is whether to destroy the last remaining stocks of live O. variola virus (WHO 2008, CDC 2011). They are not needed to produce the current vaccine and are considered a high risk for an accident or intentional release as a bioweapon (NCBI 1999).

Vaccines work

It may seem ironic that we are “celebrating” the eradication of smallpox while sheltering at home waiting for tests, treatments, and preventatives for Covid-19. But it truly is a public health milestone. I hope this story helps convince you that vaccines work. They save lives. And we need one for Covid-19 as quickly as possible.

 

Old drugs for a new disease

Map showing every known interaction between human proteins and the proteins encoded by the virus that causes Covid-19. Image from biorxiv Mar 2020

by George Taniwaki

Developing new drugs to fight disease takes a long time. In the middle of a pandemic, time is critical. But what if you could take an existing drug, one that has already been proven to be safe and where its biologic actions (therapeutic effects and undesired side effects) are known, and use it against the new Covid-19 disease? That could really save time, translating to saving a lot of lives, help restore social life, and rebuild the economy.

There are over ten thousand drugs available on the market. It would be very labor intensive to test them all in human cell cultures against the virus that causes Covid-19.  And it would be very expensive and unethical to test them all in animals. But researchers at the University of California, San Francisco have found a shortcut.

In a paper waiting to be published (biorxiv Mar 2020), a group led by David Gordon of the Quantitative Biology Institute, Coronavirus Research Group developed an interaction map between all the proteins encoded in the Covid-19 virus and all the proteins encoded by the human genome. They then searched a database of over 2,000 drugs that interact with those human proteins to identify possible candidates to repurpose for therapy against Covid-19.

They found 347 likely virus-human protein-protein interactions with 66 drug targets. They then found 69 FDA-approved drugs that may have antiviral activity. Now researchers may begin to test them to see if they can lead to treatment against this disease. A great description of the work is in Conversation, Apr 2020.

I’m hopeful that a treatment for Covid-19 become available within a few months. We’ll need it while we wait for a vaccine to be developed, produced, and distributed worldwide.