Below the Radar Transcript
Pandemic Conversations: Working the Front Lines During COVID-19 — with Dr. Kevin Patterson
Speakers: Paige Smith, Am Johal, Dr. Kevin Patterson
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Paige Smith 0:06
Hello everyone, welcome to the third episode of our Below the Radar Conversation Series. Today we speak with ICU physician and writer Dr. Kevin Patterson, about what he's learned working in the frontlines during COVID-19.
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Am Johal 0:25
Thank you, Kevin, so much for joining us on Below the Radar. I think perhaps we can just start, if you could just introduce yourself a little bit.
Kevin Patterson 0:35
Sure, I'm Kevin Patterson. I'm a writer, a novelist and a physician. I do critical care in the ICU in Nanaimo and I've been working for a long time up in the Canadian Arctic as well.
Am Johal 0:51
Great. You know, I had a chance to listen to a conversation that you had as part of the Saltspring Forum back in March as COVID was really emerging quite quickly in BC at the time, and I found it really interesting to listen to your perspective on it. It's such a new virus and for a lot of people seeing something of this scale, in size and and the rapid nature of it for many people is the first time they're seeing something like this, although in other parts of the world, there have been pandemics that have caused a lot of mortality. I'm just wondering, like from a treatment perspective as an ICU doctor or someone seeing something like the novel Coronavirus, what have you sort of learned on the, the front line as as you have seen patients and and also the rest of the medical community as well?
Kevin Patterson 1:53
Well, you know, we've, we've seen viral pneumonias for many years, and that's a usual part of the work in intensive care units, especially in the winter. Historically, these have been related largely to influenza related pneumonias, but there's other viruses that can cause this too. And as with the traditional viral pneumonias, the treatment is largely supportive. When people develop respiratory failure and they're not able to get enough oxygen in their lungs then we provide respiratory support, and if their blood pressure is low, then we give medicines to support the blood pressure, if their kidneys fail, we do dialysis. There's not, as with other viral pneumonias, there isn't specific therapy in terms of, as there is for instance, with bacterial pneumonias where we have antibiotics that work well and can turn things around. The strategy more is just to keep people alive while their own immune systems learn to mount a response that clears the virus from their bodies and hopefully results in their recovery. There are some nuances to COVID and or to SARS-CoV-2 infection, that, that we're learning we're learning that the virus is often induces a state of thrombophilia, it makes the body prone to forming clots and we're coming to understand that that's a significant part of how it injures the body by forming large and small clots from head to toe, and there's increased rates of stroke and clot related injury all over the body. And there are some technical aspects about how we set up the ventilator that is somewhat different from, from other viral pneumonias. But at the end of the day the, the treatment is supportive. And our ambition is to get people through the acute crisis until their own bodies can clear their infection and, and they can come off of life support and get better and go home.
Am Johal 4:28
Now Kevin, you're a writer as well and when something like a pandemic, comes forward and hits with such speed, a lot of questions remain unanswered in terms of how to plan for the future. We have, you know, varying places like BC and others that are opening up to a degree without really having a sense if there's going to be a second wave of this and so as there's a lot of anxiety out there. There's regional variations in terms of how the spread has happened in Ontario and Quebec and from your perspective in having looked at other pandemics historically, what are some of the issues that come up from your perspective in terms of how we should be planning not just for the fall and the spring, but but for a future pandemic as well? What are the blind spots in our thinking about how we plan for these types of events?
Kevin Patterson 5:32
Well, the first thing I would say is that there's been a tremendous blind spot in the Western World broadly about the threat that pandemics pose. The history of pandemics is as old as the history of civilization and for, for 1000s of years pandemics have surged forth and become history altering events quite regularly. There's been this anomalous period over the last sort of half century where that seemed to have abated and for reasons that don't make much sense. In retrospect, we sort of wrote off the threat, even though there was some warnings, right? I mean, when H1N1 broke out in 2009, that got our attention briefly. The first SARS epidemic in 2001 got our, or 2003 pardon me, got our attention as well. But umm the, and Ebola of course, has been a recurring issue in Africa and at times we've, we've paid attention to that. But none of these events seem to sufficed to, to get us ready in a thoroughgoing way for what we're facing now. My, my guess is that in future pandemics, we will be much better prepared in light of our experience with COVID-19. And, and I think this sense of invulnerability that characterized our pandemic planning or absence thereof, will probably not be a prominent issue for many, many years. With respect to where we are now, and looking forward to the way COVID-19 plays out over the next number of months. You know, we're all dealing, we're all swimming blind, largely. You know, this is historically, this is unprecedented within my lifetime, certainly. And we don't yet have a sense of how stringent the social isolation techniques need to be moving forward to keep the pandemic from flaring quickly. There's some early and concerning information out of Germany, having recently dialed back the social isolation measures, and they're starting to see a flare in their new caseload. Singapore has had the same problem, Japan has had the same problem, and Korea has had the same problem. So there's tremendous cause for concern, but what we're going to see now is a world scale experiment that's going to unfold over the next couple of months. A lot of people's eyes are focused on the southern American states that are decreasing isolation techniques very, very quickly, even in the face of rising case numbers. Prior to that there was measures being taken away and I hope we will learn a lot over the next several weeks and months about what is reasonable and what is not reasonable. There are some threads, some themes in the information it's coming, it's starting to seem like outdoor interactions are relatively low risk, and the total clamp down of parks and outdoor recreation might not be as necessary moving forward. It's also clear that things like nightclubs, which was the focus of the recent Korean outbreak, really are a high risk situation and it might be that nightclubs and concerts and indoor high density interactions just might not be a part of our lives for a while, maybe years. So it's, it's a topic in constant evolution and our understanding is being refined all the time. I think the next month or two will be very, very interesting.
Am Johal 9:57
You know, you're a writer as well Kevin and I was just mentioning to you before I hit record, I just read John Barry's book on The Great Influenza. I think for a lot of people, the anxiety of social isolation and other pieces that come up. What are some books that you would recommend that people read to help understand the moment related to writing about pandemics that you, that you may have come across?
Kevin Patterson 10:26
Well, John Berry's book The Great Influenza is, is a very good book, discussing the 1918 pandemic to be sure. The Coming Plague by Laurie Garrett is also quite a good book, in that was published presciently back in 1996. It examined the world's vulnerability to a new pandemic she was, she discussed influenza and a variety of potential pathogens that she thought could possibly trigger the sorts of events that are unfolding right now. Gina Kolata who writes for The New Yorker has published extensively as well about influenza, I think her book is The Great Flu and it's, it's very good too, it's, it's really the equal of John Barry's book. And the other person that I would refer everybody to is Michael Specter at the New Yorker as well who's been writing, in a really clear sighted way about the threat of pandemic infection for the last 20 years, and he wrote well about SARS, he wrote well about the 2009 H1N1 crisis, he's written about Ebola, and, and really accurately predicted a lot of, a lot of what's unfolding tragically right now emphasizing the importance of zoonosis. That's, that is to say, pathogens that leap across the species barrier as, as COVID-19 did, probably from bats, possibly through an intermediary host, that's not certain yet. And examined, you know, the way that it's exactly that sort of event that is, that makes us all quite vulnerable. Normally, when a pathogen and a host species have co evolved for a long time, there's a kind of equanimity that exists between host and pathogen and as much as it's not in the pathogens interests to kill the host off and so a relationship emerges that's, you know, if it's not, it's not exactly amicable, but it's like a long term marriage that has friction, but isn't ultimately entirely mutually destructive. But with these new zoonosis with novel pathogens, the host has not evolved to the pathogen, the pathogen has not evolved to the host. And so there's this really violent and disordered interaction that, that we see, for instance, in COVID-19, where the mortality rates are 10 to 50 times as high as that that we see with influenza, for instance. Those are, those are the writers that leap to mind. There's, there's some new good writing going on as well. Stat News has a very good coverage of COVID-19. Helen Branswell, I think is her name is doing most of it is is is quite good. And, and then there's, there's longer term writers like Roy Porter, who's who, who died just a few years ago, who's a great medical historian of our era, who wrote very, very well about tuberculosis, but a lot of those things apply. You know, he emphasized the vulnerability of socially marginalized groups and poverty and in the way poverty and crowding, renders them vastly more vulnerable to, to infectious pathologies. This is of particular relevance in Canada when one can only look on with dread at the prospect of COVID-19 getting loose among the Indigenous people, especially the reservations and the Inuit communities up north where crowding is such a big deal. The tuberculosis rate, for instance, in Nunavut is, has been compared to that in Somalia because you've got up to 20 adults living in three bedroom houses, it's just terrible. And if COVID 19 got loose up there, I think it would be disastrous. Fortunately, there hasn't been a case yet in Nunavut, but the summer is approaching and with summer there's construction workers who historically come up to the north for the summer to work and the school teachers go south, for instance. And so there's more, more interchange, more travel that's coming up. And I'm quite anxious about what's going to unfold in those communities over the next three to four months.
Am Johal 15:18
Of the large pandemics that happened in the 20th century from 1918-20, 57-58 and 68-69, are there some things that we can learn from the outcomes of those moments in some way that would help us think through the present moment. They are obviously of another era in a different context, but in, in your understanding of pandemics? Is there something that happened during those that would be helpful for us to think through how to deal with this moment?
Kevin Patterson 15:57
Well, the phenomenon that we're all preoccupied with right now is the second wave and in 1918, that was a huge, huge deal. Similarly to today's events, the first response to the outbreak was a social distancing effort and schools were shut down and swimming pools and all manner of social interchange was was dialed right back for weeks and months and and then as people grew frustrated with that there was, there emerged pressure to relax those rules and that was done. And, and a second wave followed, which was more lethal than the first wave in many circumstances. And, and then ultimately, with 1918, there was a third way that was really quite a protracted affair. And it’s hard not to look back at that historical experience, in light of where we're at right now and not be deeply concerned. The more recent influenza outbreaks in 57 and 68. are, you know, instructive, the, they resulted in over a million deaths in each circumstance. And I think COVID-19 will easily exceed those. There wasn't an influenza vaccine widely available then, just as there is not yet COVID-19 vaccine available. In 57, and 68, though the world did not, did not, you know, clamp down the way the world has clamped down for COVID-19. But that's appropriate because COVID-19 is in every measurable way, a much more threatening pathogen than those viruses were and they still managed to kill a million people in the circumstance. The contagiousness is, is dramatically higher. They, we talked about RNR the reproductive number of influenza and pandemic influenza is typically about 1.8 and seasonal influenza is lower than at 1.3 or 1.4, which is to say this is the average number of people that each new case infects and COVID-19 ranges between two to seven depending upon the context. Now it's, this is a context dependent phenomenon and when we exert aggressive social distancing techniques, we can get that R number down below one which leads to the extinguishing of the pandemic, but the problem is, is that we've only achieved that with measures that are so severe that they're not really sustainable over the long run. And the people are starting to, to cheat a little bit on their rules already, you know, there's lots of people out at the beaches in Vancouver and I'm seeing this as well on Vancouver Island and, and in the American South. People have, in many situations people really haven't adhered to them well at all and now they're just disregarding them entirely. So we'll see what the outcome of this is. And, and hopefully, hopefully things like playing soccer at the beach is going to be a low risk situation, as I feel it probably will prove to be but Quebec is talking about opening up schools quite quickly. There are already some schools opening up in Quebec. Those are the sorts of measures where you have inside close contact, difficult to isolate, they're kids after all, they're difficult to isolate from one another. Those are the situations I think that really present some serious peril.
Am Johal 20:04
As many people have pointed out, pandemics are occurring with greater frequency associated with human encroachment on the natural world and I guess, to some degree, the consequences of climate change. You know, what are some of your reflections on just the nature and the frequency of, of pandemics happening in, in recent years, and also in the near future as well?
Kevin Patterson 20:35
Well, as long as human beings are interacting with animals, there will be viruses leaping across the species barrier, and creating novel pathogens, which, for reasons we just touched on, always have a low but nonzero risk of turning into a pandemic. And so, difficult to avoid that. With influenza, the interaction is between chickens and pigs and human beings and the virus evolves in one of those three species then leaps to the other two. In Ebola, it seems that the virus came from primates that were probably taken as bushmeat in Africa. And the climate change piece becomes important there because as, as rain forest is filled, and people penetrate deeper into the forest perhaps related to food insecurity issues, then there is more and more interaction. But you know, this has always been a phenomenon. Of course, you know, HIV originally originated in primates as well, 60 or 70 years ago with or more like 100 years ago, it it leapt from primates into to human beings, most of the you know, tuberculosis did that from cattle to human beings, and possibly originally seals 1000s and 1000s of years ago. So, as long as there are other mammals and human beings on the planet, and we're interacting, these are going to be risks. I think the bigger risk is driven by density and the progressive urbanization of our societies. About 10 years ago, for the first time in human history, we now have more humans living in cities than living in rural areas. And, and as we saw in New York, and we've seen throughout the COVID-19 pandemic, density is a real risk factor for, for this contagion, as it is for all contagious diseases. Prisons, reservations, cruise ships, naval ships, these, these are all very high risk situations, because you just have so many people living cheek by jowl in these circumstances and, and that's quite a recipe for a rapid spread of infectious diseases. So there's a number of aspects to our world today that render us vulnerable. From a density point of view, even more vulnerable than we have been historically. I think human presence or human insertion into previously wild places does represent a risk, but so does human interaction with livestock, too and that's always been the case.
Am Johal 23:55
Now, you know, emergency planning in the region has had a big focus on earthquakes here. There's a lot of preparedness that was going on at the city level and provincial level. There's been some work around wildfires, but perhaps less so on pandemics. And what do you see as the weaknesses in the, in the health system and in terms of COVID coming in as rapidly as it did? There was of course, you know, shortages around ventilators and masks and those types of things. But how can public agencies, health authorities prepare better for a future pandemic?
Kevin Patterson 24:37
Well, I think the first thing we need to do is completely rethink the prominence that public health agencies have not just within our country, but around the world. The World Health Organization, for instance, has been grossly underfunded for many many years. And that has to be done away with you know, the UN spends billions and billions of dollars a year on armed peacekeeping, for instance, but as we're seeing the real threat to our society or just as real threat a to our society as armed conflict is, is pandemic outbreaks. And I would argue that pandemic preparations should be funded for at comparable levels. Certainly, certainly COVID-19's going to end up as having killed more people through its actions, I think as, as many wars have, and so that needs to change. In Canada, we can be proud that we've got some of the world's best public health teams in place. SARS broke out in Toronto in 2003 and through very skilled public health measures, and a broadly cooperative public, we were able to, to extirpate it in Toronto, and, and it died out completely, we really missed, we dodged the bullet there. The bullet has not been dodged with COVID-19, of course, but you know, Bonnie Henry has become a popular hero in British Columbia here and I think for very good reasons. You know she's very measured, transparent, effective communication. She's brought the whole public of BC onside for the most part, and, and moving forward, you know, when we get past this, we're going to just have to take a very wide ranging view of, of the vulnerabilities that exists within our societies from a public health point of view. The issue that leaps to mind, of course, is long care, long term care facilities and the kind of crowding that we allow to exist in them and the circumstances. You know, for instance, under paying the personal health care workers so badly that they have to work in multiple different nursing homes and long term care facilities in order to string together a living wage that has to just go away. You know, these rules that prevent them from working full time, so that they won't be eligible for full time benefits, that sort of thing should just be, be, that has to stop if by statute if necessary, I mean, it should stop everywhere, it shouldn't be, shouldn't be possible when you're working for Walmart either. But you know, that's just, that's just the tip of the iceberg, though, I think. I think that ongoing monitoring for contagious disease should be a part of how airports are constructed and how mass transit works and you know, there's, there's aspects of these things that haven't even occurred to us yet, I think that we need to examine and remedy to reduce our vulnerability to episodes like this in the future.
Am Johal 28:07
Kevin, is there anything you'd like to add?
Kevin Patterson 28:15
Umm, just that, you know, we're, we're gonna get through this, it's gonna be long, it's not going to be over in a few months, it's going to go on for a long time. And it's going to go away, because we take care of one another. We need to be kind and support one another, we have to keep our eyes on how the most vulnerable among us are doing at all times and do what we need to do to support them. This is as much a test of moral courage and generosity as it is of our immune systems. And the human species has prospered around the world because of our ability to cooperate and because we're a social animal, we're rendered vulnerable to pandemics, but that's also our secret superpower, that through taking care of one another, we can surmount this. This is a message that's been broadly received, I think already and we just have to sustain it and as we grow more frustrated with the changes in our lives that the infection has been, has made, we just need to understand that we all need one another to stick to these measures in order to for all of us to be saved.
Am Johal 29:33
Kevin, thank you so much for, for joining us on Below the Radar.
Kevin Patterson 29:36
Oh, my great pleasure. Thank you.
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