Whole-Picture Thinking is missing from the global pandemic response, except here and there, for medicine has devolved into sub-sub-specialties. Like the endocrinologist who understands and treats only half the thyroid, the brain injury specialist comprehends MRI but not qEEG reports, the immunologist discusses T-cell response to vaccinations but dismisses masks, the virologist educates on viral activity and vaccinations but cannot comprehend how brain injury intersects with vaccines, the epidemiologist promulgates vaccine mandates and forgets about ventilation and filtration, public health varies wildly from blunt assessment to repeating political wishful thinking, and specialists resort to the familiar talking to but not listening to patients, calling them non-compliant when the patient/public doesn’t follow orders. Exacerbating this devolution of medicine is a lack of robust grounding in anatomy, physiology, and neurophysiology and the practice of eschewing true collaboration with other specialists and professions.
It hurts people with brain injury, especially in a pandemic.
The combination has resulted in terrible pandemic leadership such that when a new mutation appears, leadership seems more concerned with pandemic fatigue and criticizing other specialists than in looking at the whole picture and collaborating across disciplines to wipe out SARS-CoV-2.
Literature shows that unprofessional and/or disruptive behaviour can negatively impact both the delivery of quality health care and patient safety and outcomes by eroding the effective communication and collaboration that underpin good medical practice (Leape, L.L., Shore, M.F., Dienstag, J.L. et. al. (2012). Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852; Sanchez, L.T. (2014). Disruptive behaviors among physicians. Journal of the American Medical Association, 312(21), 2209-2210; Leape, L.L. & Fromson, J.A. (2006). Problem doctors: is there a system-level solution? Annals of Internal Medicine, 144(2), 107-115).
From the College of Physicians and Surgeons of Ontario
Evolving to whole-picture thinking with cross-collaboration is the way out.
As a result, confused and afraid, the public rebels against vaccination and public health measures like people with brain injury do against neurostimulation after being told wrongly that strategies alone work. We all want the same thing: actionable knowledge that leads to a cure. Some talk about making COVID-19 endemic, the way brain injury experts talk about acceptance, ignoring how damaging disability from endemicity will be.
Disability Ruins Lives
Unlike flu, COVID-19 disables a significant number. Many who live with brain injury recognize its signs in Long Covid while it puzzles a medical world steeped in siloed specialties. The brain controls everything, ergo damage to the brain by a crash or virus can affect anything and everything.
Since standard medical care of brain injury ignores effective neuroplastic treatments, consigning people to lifelong disability, and and since disability supports impoverish and prevent working to full capacity, endemic COVID-19 will lead to high rates of poverty, long-term labor shortages, moral injury, and mental illness. Like with brain injury, severity does not predict who will acquire Long Covid.
But to prevent contracting COVID-19, people need a whole-picture approach. COVID-19 vaccines are a profound achievement, but they are not the kind that prevent 100 percent of disease and transmission. People also need concrete advice on masks, ventilation, filtration, physical distancing, and work and home life, like the UK government provides. Vaccines are the primary but not only slice in the Swiss Cheese model of curing the pandemic.
Swiss Cheese Model Demonstrates Whole-Picture Thinking
It’s heartening to see some medical specialists already practice whole-picture thinking, teaching us about the Swiss Cheese model, and others moving towards that way of thinking as the pandemic rages on.
The Swiss Cheese model holds that each measure, like a slice of Swiss cheese, has holes aka imperfections. But each measure’s holes aren’t in the same places, thus when layered each measure compensates for another’s imperfections. Together, the measures provide robust protection. Being honest about this, admitting evidence applies only to current understandings, compassionately responding to confusion and fear, creates trust and feelings of safety, reducing moral injury risk from siloed medicine.
In contrast to the predominant either-or approach, whole-picture thinking comprises hand washing, vaccination, masking, ventilation, filtration, physical distancing, limited contact, and income support; listens and responds with compassion instead of dividing people into siloed groups; and includes the disabled, not forces them into isolation.
Whole-Picture Thinking in Public Health Measures
Hand Washing
Hand washing is a prime example of the either-or approach. In their zeal to prove “COVID is airborne,” some experts have called cleaning surfaces “hygiene theater” and castigate the advice to wash hands. How are known ways to reduce disease suddenly bad? People need reminding to wash hands. Coca-cola has been around for over a century, almost everyone knows their name, but they continue to advertise because companies know what public health ought to — regular communication ensures people remember and do. Hand washing, the Swiss Cheese model’s first measure, prevents transmission from hand to nose.
Vaccination
The original goal was vaccination. Yet that’s changed to being vaccinated by a specific vaccine despite how SARS-CoV-2 regularly mutates to attack different vaccines’ effectiveness. McGill University researchers are tracking over 500 vaccine trials, covering the gamut of whole dead virus to mRNA, from injection to inhalation. We may discover that intranasal vaccines or dead whole-virus vaccines work best. We don’t know. That’s why vaccination must remain the goal of this measure of the Swiss Cheese model, not one particular brand or type of vaccine.
Vaccine researchers do not study the effects of vaccines on people with brain injury. This lack means people whose brains have continuous inflammation — that is, are in a perpetual state of increased immune activity that eats synapses — don’t have their regressions respected nor addressed and are isolated until whole-picture thinking to protect all takes root.
Dividing people into unvaccinated and vaccinated mimic the way specialists divide and hierarchy themselves into levels of value. It negates listening and compassion, abandons the vulnerable.
Masking
Mask design, production, adoption, and upgrading to N95s reveal how powerful our adaptation ability is despite people’s propensity to dislike change. Masks are a vital, inclusive measure in the Swiss Cheese model; worn indoors, they protect all, outside, they protect the vulnerable.
When epidemiologists negate outdoor wear, they are demonstrating siloed, not whole-picture thinking. Advising people they don’t need to wear masks outdoors means they raise risk to the vulnerable. In addition, people end up forgetting to put it on at the grocers or put it on in a rush, leading to improper fit and increased risk of acquiring COVID-19. Psychiatrists and psychologists understand how behavior algorithms work; they should form part of whole-picture guidance.
Ventilation and Filtration of Work, School, and Home
Fewer infectious particles in the air, less risk of infection. The Swiss Cheese model includes ventilation and filtration in every building and, as such, requires collaboration with HVAC engineers, their entities such as ASHRAE, AHAM, and CARB, and governments. A 2021 Cambridge study in COVID-19 surge units eradicated SARS-CoV-2 and other infectious pathogens from the air using a HEPA14/UV air filter.
Anyone who’s opened a window on a winter night or on a summer windless night knows how quickly the former cools a room and how inadequately the latter does. They understand how ventilation works. But the public has little knowledge on how to filter particles and volatile organic compounds. Cleaning indoor air is an immense task. Governments can initiate clean air programs, like clean water over a century ago to prevent cholera, and enable individuals and employers to eradicate infectious particles in the air.
Improving air quality substantially where we live, work, play, and learn improves public health.
Rapid Self-Tests
This slice of the Swiss Cheese model empowers people to independently determine at home or work if they’re infectious before attending an event.
Free self-tests add a protection layer to masking and vaccination, by letting a person determine if they’re contagious or not at that moment of self-testing. This provides people with agency, a sense of control, so important as psychiatrists and psychologists would tell you, when dealing with a virus that’s beyond all of our control.
Providing free tests, vaccines, and N95 masks and offering grants, forgivable loans, and subsidies for HEPA14/MERV17/UVC air filters includes all, protects all.
Social Determinants of Health
People need paid sick days. They also need a stable income, and government needs an efficient, effective way to ensure the population will not fear loss of income during a pandemic when everyone needs to stay home. A guaranteed livable basic income provides that.
““A GLBI is not only good for our economy but also critical to ensure that all individuals are able to live with dignity and security – rights afforded in the Canadian Charter.”
The proposed GLBI would be for all people living in Canada over the age of 17 regardless of participation in the workforce or an educational training program. The proposal would ensure cost of living is considered and that provisions are included to ensure there would be no claw back of services or benefits meant to meet an individual’s exceptional need related to health or disability.”
Guaranteed Livable Basic Income one step closer to reality. Doreen Nicoll 17 Dec 2021 https://rabble.ca/human-rights/guaranteed-livable-basic-income-one-step-closer-to-reality/
Psychiatrists, Psychologists, Palliative Care
Psychiatrists are one of the least respected medical professions. And psychologists, unless they’re part of an independent interdisciplinary team, are treated as a separate entity that have nothing to do with medicine. We can see this reflected in OHIP cutting funding for psychologists, leaving access for only the wealthy and insured. Yet both these professions can guide the pandemic response as part of a whole-picture approach through their knowledge of behavioural algorithms; how they help people with chronic illness cope with loss and grief, accept diminished life quality yet also seek out new treatments; emotional support; and, along with physicians specializing in social determinants of health, their insight into barriers. We see the latter in pockets. For example, Toronto broke away from Ontario’s public health response to take vaccines to low-income areas.
Palliative care physicians can also play a role. They deal with grief, not just end-of-life issues, in a way that supports life and quality of life no matter how little life seems left in a person.
Ending and Surviving the Pandemic
This pandemic will not end until physicians and surgeons stop competing, stop the one-upmanship. Medicine must adopt whole-picture thinking and collaboration. And we will not survive it until we become a fully supportive society that doesn’t divide but unites and sees disabled and chronically ill as a valuable part.
References
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American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). Coronavirus (COVID-19) Response Resources from ASHRAE and Others. https://www.ashrae.org/technical-resources/resources
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