Investigating the Cause of the Coronavirus - Part I31 March 2020
Part I. Identifying the Anomalies
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 I may be badly misinformed about some of what follows, and things are changing so quickly that some of it might be outdated in hours.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?
Click here to Part II.
© Henry Mintzberg, 2020. Our Zoom group, "Blind spot", 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 and Jean-Simon Létourneau, IMHL class of 2020, who pulled the group together despite their ER responsibilities in Quebec City.