Blog: Reporting Live

Investigating the Cause of the Coronavirus via Dr Snow

31 March 2020

Now is the time to revisit the story of Dr John Snow, who was selected by a poll of British physicians as their greatest one ever. This came more than a century after he was dismissed by the British medical establishment as a maverick for having questioned the accepted wisdom that Cholera had to be transmitted through the air. During an 1854 outbreak in London, he plotted pins on a map of London where each person had died. These clustered around a well, except for two outliers. He visited the home of one of them and was told that she liked the water in that well, and sent her maid to fetch it. Her niece also drank that water; she turned out to be the other outlier. And so, while the medical establishment was frantically dealing with the outbreak, the well was disabled, and the outbreak ended. Later, sewage was found to be seeping into the well from a pipe nearby.

My field is management, not medicine, although I have investigated the myths of managing health care in a book by that title. It describes the great strength of modern medicine—its capacity to categorize—as well as its debilitating weakness, namely getting stuck in those categories.

We have a number of explanations for the nature and transmission of the Coronavirus, all presumably correct (in one way if not the other). But are they adequate? There seem to be anomalies in the widely reported data: are these just curiosities, or do they reveal blindspots? Is there something else going on in the way this disease is manifesting itself? I may be badly misinformed about some of what follows, and things are changing so quickly that some of it might be outdated in hours. But if one seemingly ridiculous idea below reaches just one person who has the capacity to make something of it, then it will all be worth it. So please suspend disbelief and see if you can find one—the idea, or that person.

  • Everywhere I turn, locally and abroad, I am being told that “It’s coming! It’s coming!” But it’s not coming everywhere, only in some places. Why these places? Infections and deaths vary markedly across countries, regions, and spaces, often surprisingly so. It did come in China, or at least in Wuhan, yet not in neighboring countries, except South Korea. It has come to Italy and Spain but not Scandinavia that way. Iran has it badly, and Israel has many cases (both countries Caucasian), but not in the Arab countries in that region (even, apparently, less in southern Iran, that is more Arab). Is there something in the air, the practices, the diets? Why has this virus spread catastrophically in some confined spaces but not in some others: cruise ships, seniors’ residences, and a few Jewish weddings, but not so much in the favelas of Brazil (these surely being more densely populated that any cruise ship). Nor in rural areas and First Nation reserves in Canada. Are some countries and spaces intrinsically more—or less—at risk, and if so, why? We have some ready but inadequate explanations for this; how about some maverick ones?
  • Why do some people get the virus with no obvious exposure? Is this just a question of tracking down that exposure, or can there be some unknown form of transmission? Or might some people be intrinsically immune, and others intrinsically susceptible?
  • Italy and Germany are almost neighbors, yet the death rates have been vastly different. There are many explanations for this. Do they account for the difference? Surely the Italian population is not that much older than the German. And large teams from China were working, not only in northern Italy, but in a number of other places that have had no comparable outbreaks. Will the world continue to split into the Italys and the Germanys? If so, might there be something in the environment, the food, the lifestyle, the culture? One family in New Jersey has been devastated by deaths in two generations. They are of Italian origin. Is this an outlier that can explain something important?
  • How is it that China and South Korea seem to have arrested the spread (so far)? Can testing and confinement explain this in a country of over a billion people, whereas one person at a cocktail party or wedding in the West can infect dozens of others? Has nobody in China had a party recently?

Dr. Snow thought outside the paradigm of the time, so to speak. Our paradigms today are no different: they focus our thinking while blinding us to other possibilities. Dr. Snow used an unusual method of research by today’s medical standards, akin to detective work—better suited to investigating cause, if not to testing cure. His probe of a sample of two outliers made his case. He began with an idea and then looked at the data. His population was a targeted community.

I have been spending two hours a day on Zoom with a number of people in Quebec, mostly emergency room physicians, some working with the government health department. It has not been easy to make this argument, for good reason: they have to cope. Finally, on one of the calls, Joanne Liu, an ER doctor who just completed two terms as president of Doctors Without Borders, recalled a refugee camp in Bangladesh where an expected Cholera outbreak never materialized. She had wondered about the clay ground. Then a nurse from British Columbia, who is heading up the staffing for the response in the First Nations reserves there, commented that there had been no outbreak so far. Indeed, one member of a reserve, who recently flew in an airplane next to someone who tested positive, didn’t get it.

We set up a smaller group on Zoom—three lateral thinkers, and three seasoned physicians—to try to explain some of these anomalies. Detective work for cause has to go up every possible avenue. So here are a few, some probably absurd. Can certain medicines, themselves, beside treating a disease, make people more, or less, susceptible to the virus? We could take some common ones—for hypertension, cholesterol, anxiety—and get data on their usage in the places of high and low incidence of the virus.  (We’re trying. Hanieh Mohammadi, a doctoral student I supervise at McGill, emailed me as I write this about a report in Italy that the virus may be hitting people with Vitamin D deficiency harder.) Or how about Israel compared with the Arab states, and those Jewish weddings. Is there something in the food, the genes, the heart conditions?  Does salt or sugar consumption have something to do with susceptibility and severity? (I had had Vitamin D in this list originally, but took it out as too far-fetched!) Or those tiny plastic particles, that may be more in the air of urban and developed places? On one hand, air pollution damages the lungs. On the other, might it affect the travel of a virus that might somehow go farther than a meter or two? (I was going to take this out too, but reconsidered.) Frank Fan Xia, a business school professor in Rennes, France, wrote to me with the following comment: “Faecal-oral transmission may explain the 2003 outbreak of SARS-CoV in Hong Kong (Cotruvo et al, 2004, and Yeo et al. (2020) suggest SARS-CoV-2, which is found in patients’ faecal (Holshue et al, 2020) and toilet bowl (Ong et al, 2020), can also transmit in a faecal-oral route. If you live in an apartment/hotel building, or a cruise ship, and if any of the neighbors are infected, please use bleach to clean your toilets and drains.” Do I smell the Dr Snow story here? (Frank also mentioned aerosols and ventilation pipes.)  Who knows?

What I do know is that we should be thinking of everything possible, because some key explanation of cause might be staring us right in the face, as it did Dr Snow. Is there another Dr Snow out there?

© Henry Mintzberg, 2020. Our zoom group has been organized by galvanized participants and alumni of our International Masters for Health Leadership (imhl.org), a spinoff of our International Masters Program for Managers (impm.org). Thank you Rick Fleet, IMHL class of 2020, who pulled the group together despite his ER responsibilities in Quebec City.

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Opportunity for the G6

7 June 2018

 Elaine MartinLa Malbaie: scene of the G7 meeting. Photo credit: Elaine Martin

Will the G7 collapse in Quebec?  Then what, in a world has had it with an American President who is out of control—personally and politically—as well as with a Congress that lacks the decency to stop him. Shall we all just wait, heads in sand, for this to pass, so that noble America can once again replace nasty America?

We would do better to face the reality. A great many Americans not only voted for Donald Trump, but continue to support him. When he goes, how can trust in America be restored when we know full well that next time, or the time after, back could come the likes of him, or worse?

 Elaine MartinLa Malbaie: scene of the G7 meeting. Photo credit: Elaine Martin

Will the G7 collapse in Quebec?  Then what, in a world has had it with an American President who is out of control—personally and politically—as well as with a Congress that lacks the decency to stop him. Shall we all just wait, heads in sand, for this to pass, so that noble America can once again replace nasty America?

We would do better to face the reality. A great many Americans not only voted for Donald Trump, but continue to support him. When he goes, how can trust in America be restored when we know full well that next time, or the time after, back could come the likes of him, or worse?

This tells us that the problem goes deeper than Donald Trump, far deeper: American society is dangerously out of balance, ironically in much the same way that the communist regimes of Eastern Europe were out of balance, just on the other side of the political spectrum. The public sector dominated those regimes; the private sector dominates America.

This problem has been festering since Thomas Jefferson expressed the “hope [that] we…shall crush in it’s birth the aristocracy of our monied corporations, which dare already to challenge our government to a trial of strength...”(sic). Unfortunately, the founding fathers addressed another problem, the one that provoked their revolution: excessive power in government. Hence, they imposed checks and balances on the public sector, with no comparable checks that might have limited the power of any other sector in society.

Half a century later, the U.S. Supreme Court recognized corporations as “persons” in the eyes of the law, and took that over the edge with a decision in 2010 that extended the rights of these and real persons to fund political campaigns to their hearts’ content. In effect, the Supreme Court of America legalized bribery in the United States, and the country has not been the same since.

Who is to blame? Hillary Clinton blamed the “deplorables” who supported Donald Trump. Were they more deplorable than the established people who drove so many of them to support him: not only Hillary Clinton and the people of Goldman Sacks, but everyone else who benefits from tax advantages, union busting, meagre wages for workers, and the rest. If I want to see this kind of deplorable, even here in Canada, I look in the mirror.

Into this swamp came Donald Trump, ostensibly to drain it. Instead, he has been wallowing in it, providing the U.S. with more of the same business as usual, not least his own. Thank you Donald Trump for putting the handwriting on the wall.

A healthy society balances the collective power of governments in the public sector with the commercial interests of businesses in the private sector and the communal concerns of citizens in the plural sector (or “civil society,” if you prefer). In such a society, the three sectors hold each other in check while cooperating for constructive change. Canada maintains a better balance than does the U.S., as does Germany, France, and Japan, all members of the G7, as well as the Scandinavia countries, New Zealand, Uruguay, Costa Rica, perhaps South Korea, and maybe Brazil when it gets its act together again. The G8 lost Russia; this G7 will likely lose America, in one way or another. That’s not crisis; it’s opportunity.

Imagine a city with weak government and no police force. Gangs would roam the streets and battle with each other, or else carve up the place for their own convenience. This is our “global village”, dominated by three superpowers. A G6 has the opportunity to begin countering this, perhaps joined later by other democratic nations that have no aspirations for superpower status or recent histories of belligerence. Is this impossible? Hardly: we see the budding of it in the Trans-Pacific [Trade] Partnership that proceeds without the United States. We need solutions that seem impossible until they become obvious.

© Henry Mintzberg 2018. See Rebalancing Society…radical renewal beyond left, right, and center.

Happy Birthday Canada!

1 July 2017

Quintessentially Canadian sculpture, by Castor Canadensis; from the author’s collection

Canada is 150 years old this Saturday—as a political entity, at least. The land has been here forever, the Europeans for hundreds of years, and the aboriginals for thousands. So the number 150 is somewhat arbitrary. But this is certainly a good time to celebrate Canada: looking around the globe, including due south, where we are so inclined to look, we are an island of sanity in a sea of turmoil.

Quintessentially Canadian sculpture, by Castor Canadensis; from the author’s collection

Canada is 150 years old this Saturday—as a political entity, at least. The land has been here forever, the Europeans for hundreds of years, and the aboriginals for thousands. So the number 150 is somewhat arbitrary. But this is certainly a good time to celebrate Canada: looking around the globe, including due south, where we are so inclined to look, we are an island of sanity in a sea of turmoil.

True, we have been suffering from no Stanley Cup for our cherished hockey teams since 1993. But there is one thing even more sacred here than hockey, namely our state-funded Medicare, and that, mercifully, remains intact. Maybe this is what enables us to get on with sanity. And with democracy too, which has likewise remained intact, perhaps never better. Most of us really do strive to be tolerant in this country, and, you know what, it feels good to aim for the highest common denominator.

French culture in Quebec has long been vibrant, more recently, English-Canadian culture has become so. The multi-culturalism promoted by Prime Minister Trudeau (the elder) has been a major factor. Turn on CBC in English, or Radio Canada in French—jewels in our cultural crown—and marvel at the variety of people and faces and origins and opinions that make up this country today. In Canada, even the beavers do art, as you can see above, and more.

It was not so long ago that my uncle could not get into medical school because my own university, McGill, had a quota on Jewish applicants. Now the last three deans of medicine have been Jewish. The Conservative Party of Canada had a leadership race this year, and one of the candidates campaigned on screening immigrants for “Canadian values”. This may seem innocuous enough, but to many of us it sounded racist, a throwback to the old days of white Anglo-Saxon dominance. At the convention, in ballot after ballot, this “ideal leadership candidate” (in the words of our main newsmagazine) never made it to 8%. And this was the Conservative Party.

Twenty universities around the world have granted me honorary degrees. Yet no award do I wear as proudly as my Order of Canada. The pin we recipients wear is small—Canadian-size—yet it means so much to us, perhaps because we try not to confuse pride with patriotism in this country.

Canada is another America. It expresses another perspective by which people everywhere can see the major issues of our time, in terms of a just and tolerant world based on balance and reconciliation. We may look much like our powerful neighbor to the south, but in significant if sometimes subtle ways, we are quite different. The world at this juncture desperately needs another perspective, and quiet Canada, hidden up here in the north country, might just be providing it.¹

So happy birthday Canada! After 150 years of striving to get it right, to paraphrase from Quebec’s own Happy Birthday song, it is time to let you speak of love.

© Henry Mintzberg 1 July 2017.

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¹Three of us—a quintessentially Canadian trio, French, English, and Rumanian-born Canadians (Yvan Allaire and Mihaela Firsirotu)—have been working on a book entitled Another America: A Canadian Perspectives on World Issues. It is a collection of writings from prominent Canadians who for many years have been expressing themselves on a variety of important subjects in a remarkable cohesive way.

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