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Gandalf

January 18, 2022 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

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Open letter to my friends and colleagues: You are a COVID-19 Hero and here is your JourneyTelling the story of your journey will empower you as we defeat the pandemic

Every good story has a beginning, middle and an end. Where are you in your COVID story? 

My daughter Elizabeth, a playwright in Chicago, recently reminded me of Joseph Campbell's book, The Hero With A Thousand Faces. Campbell realized that every good adventure story can be broken into common components. He described a predictable story arc, called the Hero’s Journey, which I believe applies to most of us as we traverse the pandemic.

Let me try and reframe the sense of fatigue, loss, and exhaustion that health care workers (and others) are feeling by reminding each of you that you are on a heroic journey! A journey back to a healthy and “normal” world. Your story is one worth writing down because you will celebrate it in the future with justified pride. The work you are doing and the sacrifices you are making have value and positively alter our collective future! Your hard work and your coping with the many detours in your life plan will be a source of pride to you in the future. We have been at this for two years and it’s time to look at a map and see where we are on the course of our individual Hero’s Journey (more on that below). 

People, including most health care professionals, are struggling with wave 4 of the pandemic. Initial denial of the impact of an outbreak in Wuhan, China in early 2020, gave way to fear of the new virus, as it rapidly arrived in Canada. In early 2020 we followed new and ever-changing public health rules with diligence, struggled with business closures, and took solace in the belief “it would be over soon”. In late 2020 and early 2021 we celebrated the discovery and rollout of amazingly effective vaccines. However, in 2021 the virus mutated, accelerating its spread. We also learned that 20% or more of eligible people refused the vaccine, defying all logic and contributing to recurring waves of school closures, business shutdowns and congested hospitals that were forced to delay care for the 99% of people with diseases other than COVID-19. In hospitals, health care workers (from trainees to secretaries and technicians to nurses and physicians) are dealing with the moral distress and fatigue caused by delivering delayed or suboptimal care, the turmoil caused by worsening staffing shortages, and the fatigue that comes when one recognizes this 10K suddenly became a marathon!

This graph below shows an example of the Hero’s Journey. Recognizing your heroic role in this pandemic is empowering. You are not COVID-19’s victim- you are its worthy adversary. Through our collective (sometimes small) acts of service and self-sacrifice we will triumph.

text box with various text and 3 coloured boxes

The Hero’s Journey- we are nearing the return to the “Ordinary World”

Step 1. The Ordinary World: Our Act 1 was back in 2019-we lived in the Ordinary World. We were Shire folk, Hobbits troubled by the challenges of everyday life. We were Luke Skywalker on Tatooine, dreaming of a better future. 

hobbits house under a hill with grass

What have you done on your own Hero’s Journey to protect your home?

Step 2: The Call to Adventure: In 2020 we were called to an adventure, dealing with COVID-19. The call may have been simple (a news story you saw or marching orders form you employer). For me the call was an MAC meeting at HDH on March 10th 2020, where Dr. Gerald Evans updated us on a new virus reported in Wuhan China that was causing a fast moving and lethal respiratory illness. Here are three slides that Gerald showed which delivered the “call”. I recall this was the first time we talked about flattening the curve-a graphic we would see daily for many months. None of us knew that would come next. This is a good time for you to think about what your own call to adventure was, how you felt about it, and how you responded. Write it down! You will want to revisit your story in the future!

photo of female cartoon biting her fingersgraph showing controlled measures vs uncontrolledCOVID19 summary

The Call: COVID is coming fast and public health measures can help slow transmission and flatten the curve.

Step 3. Refusal of the call: It is typical of the hero that they feel the challenges to them starting their journey are insurmountable (until something or someone gives them the needed push). Many of us refused the call at first, typical of all heroes. “I don’t want to mask”, “I don’t accept the closure of schools and businesses”, “We just need to carry on with the old ways”. This sentiment could have been uttered by Frodo Baggins, Luke Skywalker …or you! I distinctly remember thinking that this infection would likely -be self-contained and that the early reports were over reactions. The types of changes being suggested, public masking, lockdowns, closures of key intuitions, like schools and hospitals, and restricted travel seemed too much to contemplate. 

Step 4. Meeting the mentor: In the Lord of the Rings, Gandalf was the mentor who helped Frodo realize that, weak as he was, he was the only one who could ensure that the ring left the shire. Gandalf made it clear that if Frodo didn’t engage evil was otherwise coming to his beloved home. In the case of COVID 19 who was your Gandalf? My mentors were public health officers, ID specialists, and colleagues. I quickly realized there was no way to stay in the Shire or on Tatooine. I had to take up the COVID-19 challenge because this virus was coming for us. I had no choice but to deal with it. In that recognition I crossed a threshold, and became an active COVID-19 warrior, launching this blog and frequent meetings to share information with my colleagues. Most of us were like hobbits, we felt small, insignificant in this global battle, and woefully ill prepared. We were certainly grateful for local mentors like Dr. Gerald Evans and Dr. Kieran Moore as well as international sources of trusted information, like Dr. Anthony Fauci. Who are your pandemic mentors? It’s worth noting who got you moving on your journey so you can tell you children and friends in the future. Also it’s a great idea to thank this person for mentoring you! 

photo of Gandalf holding his staff

Who is your COVID Mentor?

Step 5. Crossing the Threshold: There is that point in every story where the hero leaves the shire, departs Kansas or flies off Tatooine. In the spring of 2020 we each set out on our current journey. Some went willingly, many were forced to move forward. We all entered a Special World, a world with COVID-19. Our journey took us to an unfamiliar land with public health rules and regulations and impositions on freedoms rights that we had long assumed were written in stone.

Step 6. Test, Allies and Enemies: Once on the road every hero meets enemies, real and imagined-lions and tigers and bears, Oh my!!! On our journey we quickly encountered angry debates over masks (voluntary vs mandatory, N95 vs surgical vs cloth), stay at home orders (can they make us stay home?), closed schools (yikes) and restaurants (ouch). It was not just the virus we were battling it was 20-40% of our fellow humans who refused to follow rules and cast the pandemic as a plot, a government overreach or came up with fake science to justify their behaviours. Meanwhile, cases counts were rising, people dying, challenges to health care delivery rising and there was no cure in sight (and we couldn’t safely travel). Most frustrating there was no constancy, all policies and all message from health authorities (real and self proclaimed) were subject to debate and frequent change. My allies were my colleagues, the DOM admin team, and the IPAC team. You may want to consider who your allies were as you set out on your heroic pandemic journey. Who did you trust? Most of us have made it this far by having these friends and allies. They pick us up when we fell and encourage our better angels o…just like the friends the Fellowship of the Rings.

lord of the rings characters

Who are your COVID Companions?

At this stage in the pandemic I was calm and prepared to meet the challenge and chose action. I would enhance my Department’s support of colleagues and strive to better communicate science-based information to them a timely manner. The DOM team ramped up creative ways to thank and support residents, staff, faculty and nurses/technicians. What were you small heroic acts in the challenging days in mid to late 2020?

Step 7. Entering the Cave: This is the part in the story where the hero has to face themselves and it test their mettle. In The Empire Strikes Back, Luke entered the cave and battled Vader; only to see his own face under Vader’s helmet. With rising case numbers in wave 2 and recurring shutdowns of virtually every part of society we entered the Cave-a place where we prepared for a final battle with the virus. Here we ramped up testing, built field hospitals, redeployed health car staff, and launched virtual health care in high volume. We created new Medicine and ICU hospital beds across Ontario. We established plans to move patients around the province to avoid individual hospitals being overwhelmed. We generally prepared for battle and hoped a Gandalf-like figure might reappear with a magical spell or perhaps a vaccine! Like Luke, at this point in our journey we each recognized we had some work to do on our own response to the pandemic.

Luke Skywalker and Darth Vader fighting with light sabers

Step 8. The ordeal: Like Dorothy in the hands of the flying monkeys or hobbits being lost in Mordor, every hero hits a point and the mission looks like it may fail.For Canadians dealing with COVID in 2021 there were many low points? Stuck at home, On CERB, unemployed, struggling with home schooling, all of the above? What was your low point? In health care many of us struggled with unavoidable delays in care, recognizing the toll on the health and survival of people with diseases other than COVID-19 that was occurring. There was sadness and stress related to the loss of family visits and the challenge in assembling with colleagues for rounds. Health care was getting less patient-centered, more cumbersome, communication was suffering and with this morale declined rapidly. In a Hero’s Arc, this near-death moment either breaks us or causes us to be reborn with new courage and determination. The courage perhaps comes from realizing we had no choice but to carry on and get that ring to Mount Doom! Perhaps we were rescued from despair by rumblings that effective vaccines were being developed. The graph below shows our ordeal-a towering wave 4 fueled by the Omicron variant-our Mount Doom!

pink line graph with 4 text boxes

Step 9. The Reward: In late 2020 early 2021 vaccines emerged and the clinical trials were amazing showing >90% protection from infection and even greater protection against hospitalization and death. We now were Heroes with swords! This is where we are now on the Journey line. We can almost see the Road Home. However, we still have had to deal with antivaxxers and social media that promulgates lies and pseudoscience. These forces are the Grima Wormtoungue of our Hero’s Journey. They whisper poison in our ears and distract us from the path.

Gandalf and another from lord of the rings

Step 10. The Road Back: We are at this juncture now: I believe that between immunity from vaccines and immunity from omicron variant infections we may soon transform COVID-19 into a less frightening, endemic disease. It will still exist but will be diminished, a wraith dwelling in shadows. To walk the road home the hero must make a final push to victory. For me it is continuing to support and encourage vaccination, continuing to help ensure that in-person health care continues, and continuing to communicate. I also need to complete the COVID-19 research in my laboratory. Our team has discovered how SARS-CoV-2 kills lung cells and promotes low oxygen levels by damaging mitochondria in lung cells, We are seeking new cures. What is your contribution to the final push? Your service at work, your flexibility with overtime and your ever-changing roles? It’s worth writing your contributions down for posterity!

Step 11. Resurrection: As in any story with a hero the enemy is never quite dead until the end of the play. You think you have triumphed and omicron emerges and suddenly we have more cases and every hospital is once again full. This is where the hero recognizes that they can prevail but only if they summon up the courage to finally slay the foe. This decision doesn’t come from a place of calm and confidence; rather it comes from overcoming fear and despair and recognizing that the road home is ours to claim. To my beleaguered health care colleagues, I encourage you to consider how close we are to the road home and consider what you need to do to get you and your loved ones through the final battle.

Step 12. Returning with the Elixir: Victory will soon be ours. Indeed we can already sense this with lower case fatality rates, new treatments emerging, like Paxlovid, and clear evidence of vaccine efficacy, even against delta and Omicron variants.

various bottles of different manufacturers COVID19 vaccine

What is coming is an era of return to a more open society, hospitals that resemble those we once worked in and the banishing of bleach-loving, vaccine denying, public health-opposing forces to the margins. These people will have a story too, although it will not have the Hero’s Journey. Rather it will be a story of being on the wrong side of history but I suspect it will quickly be forgotten and sanitized (by them). One thing that it always true it that once we finish this journey we will be “back home”; but Kansas will never be the same. We will no longer be the same timid Hobbits we were before our journey. 

tin man, dorothy, scarecrow and lion from wizard of oz

I encourage you to be proud of your journey! However modest, we have each made a difference and in your own hobbit ways are heroes. You will be stronger and happier if you embrace the fact that you are a hero; even if you are a reluctant warrior! Write down the milestones in your Hero’s Journey and you may be reminded how much you have done; how remarkable you are and realize we are going to complete this journey and claim victory.

Keep the faith-I am proud to be walking with you on your Hero’s Journey

screenshot of Amazon book order

Here is a short clip on Joseph Campbell and his book, The Hero with a Thousand Faces. 

Envision your face on the cover!

1) KFL&A update: Wave 4 improving with 128 new cases/day, falling positive test rates ~9.5% (down from 16% last week), and 652 active cases (only 25% the number a week ago), and 28 patients hospitalized .

2) Ontario’s 4thwave declining: New and active cases are down 20% and 32%, respectively, while hospitalizations rose 45%, deaths up 67% 

3) Canada’s COVID-19, omicron-driven 4th wave receding: 30% decrease in new cases and a 18% decrease in active cases with a 37% increase in hospitalizations (click here) (click here)

4) How effective are vaccines? Ask the Swiss (VERY!)

5) Global vaccine roll-out 9.71 billion doses administered and 60% of all people have received at least 1 dose BUT only 9.6% of people in low-income countries have had a single dose. Vaccine safety record remains excellent (click here)

6) The global pandemic is still increasing: ~331.5 million cases and 5,548,410 deaths to date with widely varying cases fatality ratios (from Canada at 1.35% to Yemen at 19.2%)

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1) KFL&A update: Wave 4 improving with 128 new cases/day, falling positive test rates ~9.5% (down from 16% last week), and 652 active cases (only 25% the number a week ago), and 28 patients hospitalized .

The graph below illustrates that cases are declining in our region (orange line).

line graphred and green line graph

Moreover, our local rates of Positive COVID-19 test rates, though high, are declining (green line below).

In general, allowing for the fact we are doing less testing, case rates in SE Ontario are declining (graph below).

blue line graph

The medical wards remains very busy with 190 in-patients. We have adequate ventilator and also have capacity to handle our regional acute care needs. That said, surgeries and any elective acute care are being reduced as required by Ontario Health’s Directive 2 to maintain bed capacity by Ontario Health. We continue to struggle with the perpetual problem of loss of beds to the housing of Alternate Level of Care people (ALC). ALC people are people who do not require hospitalization but rather are in hospital because they lack a spot (or decline a spot) in a retirement home or nursing home and/or cannot access community social/health services adequately to meet their care needs. There are ~ 80 ALC people at KHSC. This does not benefit these people and limits our capacity to provide acute health care (read more here).

2) Ontario’s 4th wave declining: New and active cases are down 20% and 32%, respectively, while hospitalizations rose 45%, and deaths are up 67% COVID-19 hospitalizations and deaths always lag 2-4 weeks behind peaks in case numbers. Thus we are now seeing the sad but expected rise in hospitalizations and deaths following the omicron case peak; fortunately at a much lower rate than we saw with the delta variant. In general we appear to have peaked and hopefully case numbers will continue to decline so that wave 4 ends in the next several weeks.

salmon coloured line graphsalmon coloured line graph

Wave 4 beginning to resolve in Ontario (orange) and SE Ontario (Blue)

3) Canada’s COVID-19, omicron-driven 4th wave receding: 30% decrease in new cases and a 18% decrease in active cases with a 37% increase in hospitalizations (click here) (click here)

map of Canadasalmon coloured line graph with 4 text boxes

COVID-19 cases in Canada are falling (with the usual lag in hospitalizations and deaths which are increasing post-peak of wave 4), Jan 18th 2022

79.6% of people 5-years of age and older have had at least 2 vaccination doses (see graph below). Canada has had 2.81 million cases of COVID-19 since the pandemic began. The case mortality rate remains ~1.35% with 31,806 deaths. We have administered a total of >73.9 million vaccines!

4) How effective are vaccines? Ask the Swiss (VERY!)

A graph, courtesy of Dr Gerald Evans, is worth a thousand words. These data from Switzerland show the effects of 2 and 3 doses of vaccine on mortality! A 26-fold degree of protection from death obtained at a very low a risk of a serious but nonlife threating reactions to the vaccines (only 1/10,000 people). Please share this intel with any unvaccinated friends.

colourful horizontal line graphs

5) Global vaccine roll-out 9.71 billion doses administered and 60% of all people have received at least 1 dose BUT only 9.6% of people in low-income countries have had a single dose. Vaccine safety record remains excellent (click here)

world map with various shades of green

Vaccination rates remain appallingly low in low-income countries, many of which are in Africa (above). These vaccine deserts allow unnecessary human death and suffering and have allowed the virus fertile ground to mutate, the genesis of the Omicron variant. We need to learn to help ourselves by helping others!

Vaccines are safe: You may be interested in this recent blog, “Vaccines for COVID-19: Why are some Canadians allergic to the truth?” The blog reminds us how effective vaccines are (see graphic below) and how rare true allergic reactions are. 

In addition to many clinical trials showing safety, the safety record of vaccines has been established in the real world. The complication rates remain very low based on Canadian data, which show that vaccines are safe (click here for Canada’s safety data), as well as being effective against all forms of the coronavirus. Getting vaccinated reduces your risk of infection, hospitalization, and death. It also makes you less likely to transmit the virus to others. Vaccination carries a very small risk of serious adverse reactions and virtually no risk of death.

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The serious complication rate of COVID-19 vaccines remains low in Canada (10 serious adverse events per 100,000 vaccines administered). Data as of Jan 7th, 2022

6) The global pandemic is still increasing: ~331.5 million cases and 5,548,410 deaths to date with widely varying cases fatality ratios (from Canada at 1.35% to Yemen at 19.2%)

satellite image of earth taken from spacemap of the world with graphs and ranking of countries leading in covid 19 cases

Here is today’s map of the global pandemic. Daily cases are soaring due to the high infectivity of the omicron variant (red graph) but deaths have begun to decline (white graph). It is uncertain if this fall in mortality reflects the impact of vaccines, omicron’s lower mortality rate or other factors, such as under-reporting Vaccine administration remains high (green graph), albeit heterogenous in distribution (low in Africa). The white dots on the map are case fatality rates.

Stay well and keep the faith-continue on your Hero’s Journey and we will emerge from this pandemic intact!

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