Hot topics in COVID-19 with Dr. Ross Upshur

With the pandemic of COVID-19 spreading everywhere around the world right now, there's a lot of fear, frustration, and anxiety. On the flip side, there's a lot of innovation, connectedness in novel ways and reflection going on. In the spirit of physically distancing ourselves and innovating, we've decided to continue our podcast through Zoom. Today, we interviewed Ross Upshur, and discussed hot topics in COVID-19.

Recorded on March 25, 2020.

Additional links (provided by guest speaker):

1. Very clear explanation of the effect of distancing and other measures on spread of virus - https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56
2. Cool visualization and explanation of pandemics - https://www.visualcapitalist.com/history-of-pandemics-deadliest/  
3. MPH FCM Advanced standing -  http://www.dlsph.utoronto.ca/program/mph-family-and-community-medicine-advanced-standing/
4. MPH - https://dfcm.utoronto.ca/mph-fcm

Transcript

Dr. Rezmovitz: 0:00

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. With the pandemic of COVID-19 spreading everywhere around the world right now, there's a lot of fear, frustration, and anxiety. On the flip side, there's a lot of innovation, connectedness in novel ways and reflection going on. In the spirit of physically distancing ourselves and innovating, we've decided to continue our podcast through Zoom. Today, we interviewed Ross Upshur, and discussed hot topics in COVID-19. Take a listen and I hope you enjoy our conversation. Stay safe and be well.

Dr. Upshur: 0:51

So some of the questions- so the work that I'm doing right now is not so much clinical, but I'm an advisor to advisors. So I'm working with the World Health Organization, with Medecins Sans Frontieres, Public Health Agency of Canada, Ministry of Health, and also doing a lot of work from the point of view of the School of Public Health. So yesterday I was the moderator of a panel where we were looking at new tools that are being developed that allow a better understanding of the evolution of the outbreak in terms of modeling in the community and modeling the demand for hospital services. So I've worked- and so the backstory, uh, is that after- so it would start actually with SARS. So Sunnybrook was- you're asking- I'm already talking-

Dr. Rezmovitz: 1:50

[inaudible]

Dr. Upshur: 1:50

So in SARS- Sunnybrook was a SARS hospital, so we basically closed the doors to the clinic and started sending people doing house calls. I got seconded out to York Region Public Health because I actually have specialty training in public health medicine and I'm kind of like a pryer, cruder version of Jeff Kwong. I was doing a lot of work on modeling respiratory disease in populations using ICES data. So I started out as a communicable disease modeler. I did work on outbreak investigations while I was a resident and have always kept my foot in that element of public health because during SARS, I went to York Region to do the modeling and figuring out the patterns of spread of SARS in the community, but it never spread in the community. It was a nosocomial outbreak. So I got dragged- I got brought in to be doing medical officer of health work and I ended up being the quarantine enforcer. So that led me to start to think about ethical issues in public health response with colleagues at the joint center for bioethics. We published a paper in the British Medical Journal. We also added a section to the Naylor report and that turned into a white paper called Stand on Guard for Thee, which sets out the kind of principle ethical issues that will be raised in a pandemic. We were thinking about influenza, but they're actually germane to coronavirus. That then became the template of the World Health Organization guidance document. That's how I started working with the World Health Organization. I chaired the working group on health workers' obligations to care in a pandemic. And then we were also- that was around the time I became the director of the Joint Centre for Bioethics, and I was the director of the WHO Collaborating Centre for Bioethics. After I stepped down from that role, I became- still part of the collaborating center, but I've had the lead for ethics and epidemics ever since. So that means I've worked on SARS, MERS to a certain extent, pandemic H1N1 influenza, both Ebola outbreaks, I took a little bit of a pass on Zika, but I was still peripherally involved. And so what we find are the same issues arising again and again. So first issues- and it depends on when they arise. So right now there's a big concern around resource allocation. How do you fairly allocate resources and scarcity? So we had a paper published in the New England Journal of Medicine on Monday that sets out some principles that you might want to think about for allocating things like ICU beds, hospital admissions, and then into personal protective equipment.

Dr. Rezmovitz: 5:10

I'd like to talk about that if you don't mind. I read that article.

Dr. Upshur: 5:13

Yeah.

Dr. Rezmovitz: 5:14

And so, but first I'd like to say that you set out a framework for ethical principles to guide how to plan pandemically. But at first, I think we need to state that I- at least I in this conversation in this world- think you have intrinsic value as we get into a guide of ethical principles that guide this. Okay?

Dr. Upshur: 5:33

Yes.

Dr. Rezmovitz: 5:34

Based on everything you just said, I think you bring a lot of intrinsic value, for the sake of just valuing what we should be doing because we're going to get into a talk about values obviously.

Dr. Upshur: 5:44

Yes.

Dr. Rezmovitz: 5:45

So I just want to let you know because I think we've- on our previous talks, we both had mentioned that nobody really listens to us at home.

Dr. Upshur: 5:52

Yeah.

Dr. Rezmovitz: 5:52

And so I[ inaudible] today. Okay. So let's talk-

Dr. Upshur: 5:59

The irony is people now want to read stuff I wrote 15 years ago on the justification of quarantine, how you figure out what the limits of responsibility are in a pandemic- it's quite remarkable. And then of course, all the stuff that I was working on how we understand and interpret and utilize evidence. So-

Dr. Rezmovitz: 6:23

Didn't you- aren't you the one that wrote that- those that don't learn their lessons are deemed to repeat it or something?

Dr. Upshur: 6:29

Well, that's a[inaudible] So the person who wrote that is George Santayana, who is a famous American philosopher. He's remembered for that quotation and people actually forget where that quotation came from. It was on a four volume book that he wrote on the history of reason in society. And of course, the idea is that we actually don't like to learn our lessons from the past. That's why we're condemned to repeat them.

Dr. Rezmovitz: 7:01

Oh that's the line.

Dr. Upshur: 7:02

Yeah. So that comes to- towards the end I think of the third volume- I've got it written down, I always mess it up. And so after the Ebola outbreak in 2014 with one of my PhD students, we wrote a paper about lessons learned from epidemics. And the only lesson we learned is that we don't like to learn lessons because- and I have this whole riff which I set it up that- SARS was a wake up call and we have to learn lessons. A couple of years later, H1N1- a wake up call. We have to learn lessons. Ebola, a wake up call. We have to learn lessons- and I kind of recapitulate all of those arguments- they're all the same lessons. So we either have collective amnesia cause we keep forgetting, or collective narcolepsy because we keep needing to be woken up. And so the same recurrent issues- resource allocation, use of restrictive measures, global governance and global citizenship, health workers' obligations to care keep coming up, and they are playing out in spades with the coronavirus outbreak.

Dr. Rezmovitz: 8:09

Yeah. We are definitely at risk because of not learning our past lessons.

Dr. Upshur: 8:15

Yep.

Dr. Rezmovitz: 8:15

It's really scary actually. I'm a community doctor and I mean I don't have the amount of personal protective equipment necessary to see patients daily.[ inaudible] We switched to video, but there are still things that you can't not see. And we're talking about your main things, like taking staples out of somebody who's post-op- I can't let the skin grow over the staples. You still have to see people and just- it puts people at risk.

Dr. Upshur: 8:47

Yeah. So there's a couple of framing considerations to contextualize concerns about duty to care. So one thing to remember is that for most of human history, physicians cared for patients without any personal protective equipment. If you go to the original codes of ethics for both the Canadian Medical Association and the American Medical Association, written in the late 19th century around the time we started to appreciate antisepsis, there are provisions in there that say during times of pestilence, it is the physician's duty to care for the patient even at risk to their own lives.

Dr. Rezmovitz: 9:31

That's right.

Dr. Upshur: 9:32

The other thing is that globally, it's a planet inhabited by 7 billion people, the vast proportion of whom are served in healthcare services where they don't have running water or soap. So when I was convening, the global group for the pandemic influenza guidelines, we had to come up with advice for all the healthcare workers in the world. And I remember writing that minimally, we want to make sure that they have access to soap and water. And I was told that that is something that could not be reliably secured for all healthcare workers on the planet. So we are- I'm not saying that personal protective equipment isn't important- don't misconstrue my argument- but the reality is many of our peers and colleagues and, and we can't in a- if we're going to truly take global solidarity into account for a global pandemic, our peers in many health systems are going to be providing care without any personal protective equipment. Now, after SARS, there was a big issue about whether in that- again, the Campbell Commission report is a lengthy report written by Justice Campbell- looking at whether leaders in both government and in health institutions were diligent enough in taking steps to protect healthcare providers. The argument was, of course, that they didn't, and going forward in the future in all pandemics, we should be optimally prepared to protect all of our healthcare providers. And I'm getting the same calls because a lot of my classmates and friends are community based family docs. And I understand their concerns. So we're going to have to kluge a solution on the fly rather than as recommended in many of our guidance documents to actually have policies and procedures in place about who's going to do what in the event of something like this happening.

Dr. Rezmovitz: 11:47

So we have a lot of guidance right now, and as you've seen there's Plan A, which is what the ideal plans are to- you know, enough personal protective equipment to go around. There's Plan B- reusable, personal protective equipment. And there's Plan C, which is we wish you the best of luck and we hope you don't get it. So how are we like- we have a couple of systems that we get to look at right now. So one- you're at the Dalla Lana School of Public Health in Toronto. So we look at Toronto, we can look at Ontario, we could look at Canada, we could look at North America, and then we can obviously go global here. So my question to you is, what should we be focusing on right now as community doctors? And we can talk about each system, I guess. What can we do? Like I guess when I might say what my focus is, or what should our focus be- should we be focusing on prevention? Should we be focusing on cure? Like how can we all- I think everybody wants to contribute somehow. What should we be focusing on?

Dr. Upshur: 12:55

So I think one key thing that family physicians can do now is be trusted communicators of good information. And that may mean- I think everybody's going to have to go back and say,"gee, I wish I paid more attention in medical school to all the lectures I had on public health and why it's important." And the public health messaging- and I've been pleased by how it's been supported by the clinical world. I think people who look at the numbers and see what's happening in Italy and Spain in particular- the last thing they want is something like that happening here. And our best chance at preventing that- and this is the prevention message- is to support and uphold the physical distancing measures that are put in place. And one of the things I've been circulating is a brilliant document that actually walks through the population health rationale for why we need to act this way. So, yes, some of it's based on modeling, but those models are now well informed by data from China, from Italy. It's our best chance for something to work. So if we get a bunch of family physicians saying- following along the pages of Trump saying,"well, the cure is worse than the disease, let's just get back to normal." If we have, if we have people who are respected in their communities because they're leaders of their medical societies falling off message, that's going to be harmful. The second thing is yes, we may not have all the personal protective equipment we want, but if we don't provide care for our patients who will? So t here's a set of independent reasons based in our capacity to be a self-regulating profession that obliges us to be the ones that provide care- I know this doesn't make me popular- even if we may need to take on a bit of additional risk. Now we're going to have to look in our own souls, each and one of us individually, about where we draw that line, but if patients who are looking for care, if they don't come to see us, they'll show up in the emergency. Somebody somewhere is going to have to care for sick patients. And we have a whole system called medicine and we train people called physicians. We give them particular privileges in our society to do things because they've got an exclusive license to do things like diagnose, prescribe, and so there's a bit of a soft social contract that gives physicians the authority and power to do the things they do. And I have this feeling that if we don't show up that might be renegotiated and we could become a wage earners and employees like other jobs.

Dr. Rezmovitz: 15:57

Yeah.

Dr. Upshur: 16:00

And we've got the skills right because of our training. We know more about how to treat the sick than other people in society, despite Google's doctors and all the other methods that people seek out for information. So that's reflecting on why we have the authority, the prestige, the kind of- why we're considered a profession, why we have licenses, why we have training programs and all of the social resources that are invested to produce us as physicians, I think does give us a particular obligation to find ways to ensure that we're responding to the health needs in a time of crisis.

Dr. Rezmovitz: 16:41

It's almost as if what you're saying is we have a fiduciary duty- almost like we took an oath.

Dr. Upshur: 16:46

Yeah. You know, imagine that. Imagine that we actually are fiduciaries. Yes, we are. And that's what the law is. So if you look at the College of Physicians and Surgeons of Ontario, they have a policy on this and it's very clear. There is an expectation that we will provide care. We went through- and I can send you all the- we did a lot of studies on this and the public is supportive in some of our survey work in our focus group work- of reasonable accommodations. So for example, if there are physicians who, for reason of age and morbidity may be put at particular risk, it would be advisable to repurpose them to do work that doesn't put them in harm's way. And of course that's why we have- but you're going to need to work it out in your own clinics. So younger, healthier physicians who are more likely to withstand a COVID infection should they get, it would be the first line of defense. But we should have had all of these policies and procedures and guidance documents hammered out in advance instead of scurrying to put them together now.

Dr. Rezmovitz: 18:04

I'm lucky- I work as a solo practitioner.

Dr. Upshur: 18:07

You're on your own, right? You have very little backup. So I mean, I had this intuition back when we were doing a lot of this research when we were interviewing people after SARS and people are saying,"you know, I didn't sign up for this. I didn't think I could get ill in this way, in my work." And I was thinking,"really?"

Dr. Rezmovitz: 18:35

Like touching sick people?

Dr. Upshur: 18:37

Like, you didn't really think that you could be put in the way of infection by becoming a healthcare provider? So it's like we've- and I actually tried to get this as a kind of screening question when on admissions interviews, right?"Do you know that by becoming a physician you will be exposed to every bug that's out there?" And particularly if you've got a large pediatric population that you serve. I mean, everybody knows and remembers from their internship and their residency, when doing pediatrics, your immune system gets reintroduced to a lot of- just like when your kids are young, right? So we are in one of the riskiest possible occupations for being infected in the course of our duties. We always have- since time immemorial- Hippocrates recognized this.

Dr. Rezmovitz: 19:31

So let me ask you then, given that we are at risk, and given that we've got these ethical guidelines driving us or guiding us on how to respond, what is the best way to test or identify people at risk and should healthcare workers be getting tested more often?

Dr. Upshur: 20:00

In terms of- testing for coronavirus you mean? Or tested for their emotional and psychological resiliency to perform the tasks that they're are required by their jobs?

Dr. Rezmovitz: 20:13

Is there a test for the latter?

Dr. Upshur: 20:15

I don't think so.[inaudible]

Dr. Rezmovitz: 20:21

I'm really talking about testing as far as antibody testing, I'm talking about NPs, I'm talking about- you know what? I'm not going to put down qualitative data, but if you ask"how are you feeling today?" And they're like,"I can't do this anymore," that's a valid response.

Dr. Upshur: 20:41

I agree. So one of the sort of buffers to the duty to care obligations of physicians- you'll see this in the priority setting- thinking that people like physicians, nurses, healthcare providers who are on the front line actually have- when it comes to if we have medications, if we have vaccines- they have a good argument to being higher on the priority list for receipt of those goods. And so when we're going to be working through the PPE priority setting, it's clearly going to be going to people who are on the front lines working in healthcare that have first claim on it over and above other essential services we may have a duty to protect, but they're really not on the firing line in terms of exposure. I'm not sure if you saw it- The New York Times has had some fabulous graphics, but they had this one tool that allowed- it had the risk of exposure and the probability of exposure and harm by occupational categories. And of course, the far- you think of the axes, up here in the top right was like 100% likelihood of exposure and 100% risk. And family physicians are on the top of that list. And so you can see where- and it has this whole kind of sweep of it. So because we're at such a risk, that means that when it comes to handing out or distributing scarce resources, they have a first claim because of that. As opposed to they had artists and sculptors who were way down at the bottom of like- their probability of exposure is low and their risk of being ill because of their mode of work is also low.

Dr. Rezmovitz: 22:51

But healthcare workers have an instrumental value towards improving the health of everybody.

Dr. Upshur: 22:55

Yes. And that's part of- that's another additional argument in favor of their being high on the priority list.

Dr. Rezmovitz: 23:03

Right. Now, I've been reading this journal recently- it's a great journal- it's called The New Yorker. It's one of my favorite journals. Have you read Atul Gawande's article about keeping the coronavirus from affecting healthcare workers?

Dr. Upshur: 23:18

No, I haven't read that yet. I've got a big stack of- we have a subscription, so they tend to get stacked up and I read them in bulk when I'm on holiday, so I'll definitely track that one down. What did he have to say? Because he's usually quite insightful.

Dr. Rezmovitz: 23:35

He is. So he's saying that- well first of all, the testing that they're doing in Singapore, in Hong Kong, and in China is much different than the testing we're doing. They're making sure that there are no false negatives.

Dr. Upshur: 23:48

Yeah.

Dr. Rezmovitz: 23:49

Three and four tests going out before they're saying somebody recovered completely.

Dr. Upshur: 23:54

Yeah.

Dr. Rezmovitz: 23:55

And they're making sure that their healthcare workers are completely covered. What they did from the onset is that they put down- they did a mass lockdown and they made sure that every healthcare worker used personal protective equipment, mask, goggles, visors- basically hazmat suits, to see every patient regardless of what they had.

Dr. Upshur: 24:17

Yeah.

Dr. Rezmovitz: 24:18

And it's shutting it down. And they tested the people who got infect- if you were infected, they track down any contacts and they put those people in quarantine also. And so we're not seeing the same rise that we're seeing in Italy, the US now, right? And I'm afraid that Ontario was gonna escalate into this.

Dr. Upshur: 24:40

Well, I've been working on this thing called clinical public health, and I think this is a nice illustration of its importance. So a lot of people are pointing to the effectiveness of China, Singapore, Hong Kong, Korea, and conditioning on the implementation of restrictions and lock downs. But as you pointed out- and if you read the WHO report on the high blue ribbon panel went over and issued a report- China mobilized 10,000 teams of five people each, of contact tracers and testers in the community. Good old fashioned- what I'd call shoe leather epidemiology. And of course, the ones they were avidly after were the contacts of people in healthcare who became exposed. So it's not just the restrictions, it's testing and tracing and following up in the community. And they continued with that- even when there was intense transmission in the community. In other words, they didn't succumb to nihilism that now that we're in tertiary spread, you can't track it down anymore, there's no point in contact tracing and testing. They did not surrender on that front. They also brought every CT scan they could move into Wuhan and they mobilized a large number of healthcare providers to go and work there. So it was a multipronged intervention. And so teasing out or- and they had mobile apps and all sorts of things. It wasn't any one of them- it's really hard to estimate which was the most effective of them all, but they combined. And now we can contrast because certain other systems have used different methods, and now modelers are actually able to estimate what they think the contribution of each of these independent strategies are to the control of the disease- and I'll flip you a link to a paper that shows how all of this is calculated. And I think that's something that health care providers- physicians in particular would be- I'm sending it to all my physician friends because it actually explains the epi and the rationale and provides the data for why this may or may not work.

Dr. Rezmovitz: 26:57

That's amazing. One of your titles- is it director at the Dalla Lana School of Public Health?

Dr. Upshur: 27:09

Division head.

Dr. Rezmovitz: 27:10

Division head- sorry, I knew it started with a D. How can we then mobilize and use our sentinels, our family doctors or primary care physicians in the community better? How can this be better? Because today I got a call this morning from a really nice friend of mine who said,"by the way, do you have enough equipment in your office to make sure that people aren't going to emerge so that you're taking care of your patients?" And I said,"no." And he said,"well, here's the name of someone. We can do a mass order." And so I've been talking with this gentleman about centralizing distribution for Toronto, for Ontario, for PPE because- and then we started talking about resources, and information, and specialists consults, and the need to actually set things up so that we start thinking about how we can do things better in the future- preparing for-

Dr. Upshur: 28:15

Yeah. All that stuff that we were talking about.

Dr. Rezmovitz: 28:17

Yeah. All the lessons. And so, the funny thing is- so here I am, this morning- I sent an email out to my physician health organization or family health organization and I said,"who needs PPE for their office?" So it's like 26 physicians in my group and I'm getting emails back from people who are like,"I need this many boxes. And we're trying to cover a front office staff." We're trying to do the calculation: patients, front office staff, the physician themselves, nurses, and it's really, really expensive to use single use masks or single use equipment every time one patient comes in because you look at the exponential use of PPE. And the interesting thing is somebody called me who was on the list and said,"why are you doing this?" And I said,"what do you mean?" He said,"why would you pay for this equipment? This should be coming from Public Health. Why would you waste your money and spend it yourself?" I said,"well, Public Health isn't giving out enough PPE to everybody-"

Dr. Upshur: 29:19

So just for correction, it's not Public Health that gives that out. It's the Ministry of Health.

Dr. Rezmovitz: 29:24

The Ministry of Health gives out the SARS kits or gave out the SARS kits?

Dr. Upshur: 29:27

They're the ones that are responsible for much of the procurement and distribution.

Dr. Rezmovitz: 29:34

Regardless. So the Ministry of Health. But they don't seem to be mobilizing anytime soon and giving out these kits and doing everything. So we have to mobilize and start doing these things ourselves. Like I said, we have this fiduciary duty to care for people.

Dr. Upshur: 29:49

Yeah.

Dr. Rezmovitz: 29:50

Easy. Absolutely crazy. So as we get more and more PPE- because they will come in and as we see the cases rise in Ontario- God willing, it does not- but if we see it, what can we do as family physicians to mobilize? How can we best be utilized on the front line to improve this?

Dr. Upshur: 30:11

Yeah. So here we're going to run up against a reality that's dawned on some of us a couple of decades ago. We like to talk about us having a healthcare system when we don't have a system.

Dr. Rezmovitz: 30:24

We have a healthcare system. We don't have a sick care system. We can take care of healthy people very well.

Dr. Upshur: 30:31

Well, we have services. We have an abundance of services, but there's no central processing unit. So to assist them apart and whole, connect, and relate to each other. So interestingly, I've been teaching this course in the MPH Family and Community Medicine on history, philosophy and ethics of public health. So the last lecture I gave was all of the reasons why we don't have a system and why we need a system. My frustration at what's playing out is quite considerable because we did have an opportunity- and I kind of walked back through the history from Flexner to the present on- people think,"Oh, well, Flexner said nothing about public health." Absolutely not. He had a fair amount of things to say about the importance of public health and its integration with clinical care. My favorite report is the 1964 Royal Commission on health services and physicians and human health resources. It was the companion to the Hall Report, which led to the founding of Medicare. And time after time after time, they make the point about how it's important for public health to be integrated with clinical care. They bemoan the fact that public health physicians have become indifferent to the clinical world, and that clinicians h ave become indifferent to public health and hygiene, and how we need to reconstruct our education and our educational systems, and our healthcare system delivery to better integrate. So this whole thing, when I started clinical public health and e veryone said,"Oh, that's an oxymoron. You can't have clinical and public health in the same sentence or than the same phrase because c linical i s over here- I see one patient at a time- and public health is over here- we don't do individual service delivery." That was exactly the polarization that the Royal Commission identified in the early sixties before we even designed our current system to avoid. Yet we did our very best to actually silo and separate those worlds. That was called out again i n the N aylor Commission that these solitudes can no longer exist. So maybe after this we'll get our act together and build systems up. So what can family physicians do? A huge amount. So y ou mentioned sentinel surveillance being the eyes and ears on the ground as to what's happening in the community, but feeding that to somebody who's actually g onna do something and feed it back to you in real time, in a dynamic way so that people on the front lines are always informed by the best epidemiological data, they're told what works and what doesn't work, but we need to actually purposefully build that system.

Dr. Rezmovitz: 33:32

So I'd love to operationalize at least one thing out of this talk this morning. Other than mobilizing PPE so frontline workers can start doing testing, the problem is getting tests, right? That's the second barrier to all this is that there's a bottleneck on the amount of tests that we have. You know, I'm part of the Sentinel Network for influenza and so they push-

Dr. Upshur: 33:59

Well done.

Dr. Rezmovitz: 34:00

Thank you. And so they pushed out a notice that said,"well you can start using the NP swabs for Corona virus." Well, that's great. Fantastic. I said,"please send me some more swabs." And they said,"sure, we'll send you five." Okay. I'm willing to put myself out there to help swab so we don't have to go to an assessment center where I can do everything myself here. And you're giving me five. Well, I got a call two days ago to give up all of my swabs so it can go to St Mike's because they're at a scarcity of, of swabs right now. So I gave up my swabs because I don't even have the PPE to last more than three days here if I was to see 60 patients, I mean forget it. What am I supposed to do?

Dr. Upshur: 34:49

So this is- I'm going to speak, frankly- this is scandalous that we should be in a situation of facing a major respiratory pandemic, and you've been offered up five swabs and it has to go to one of the major academic health science centers because they're short. How is this possible?

Dr. Rezmovitz: 35:15

I didn't have to, it's just that I'm offering it- I've been asked.

Dr. Upshur: 35:19

Yeah, I know, but I think it was a legitimate thing to do.

Dr. Rezmovitz: 35:25

Right. The other issue is that you can see barriers everywhere. Three weeks ago when I ordered hand sanitizer, the major suppliers to medical offices in Toronto- Medical Mart and Surgo, Medical Mart was back ordered and Surgo said,"Oh, sure, but we've tripled the price."

Dr. Upshur: 35:47

Yeah.

Dr. Rezmovitz: 35:48

So we've got capitalism versus like social democracy and human rights.

Dr. Upshur: 35:58

Yep.

Dr. Rezmovitz: 35:59

I don't know if purchasing hand sanitizer is a human right, but we're trying to do our best here and to be able to then raise the price because of your capitalistic principles seems unjust, I guess.

Dr. Upshur: 36:14

Well, it is. And in my dark moments- because I've been hearing a lot of different accounts sitting at a table with people from the World Health Organization about how creative profiteering has become, and all the ways that people are looking to make money out of this unfortunate event. And it kind of reminded me- I don't know if you've ever seen the movie Orson Welles' The Third Man. So Orson Welles plays this guy Harry Lime, who's a profiteer- he's a black market of penicillin. And this is just after the end of the second world war. So he's a real nefarious character. It's an excellent movie to watch. So I was thinking we need to come up with kind of a Harry Lime shame award for the most egregious profiteering and use social media to sort of like" no, you can't do this." I think the government should be very clear on going in and checking and calling out and regulating price increases for materials- unless, the manufacturer can say, my costs have gone up, and prove that. But if their production costs haven't gone up and they're just making their- they're trying to increase their profit margins, of course that should be discouraged by all means necessary.

Dr. Rezmovitz: 37:39

Yeah. So that still leaves us with- I just want to get your comments on whether or not we should be doing blood tests then for antibodies. Are we at that point yet where we can- have you heard anything yet?

Dr. Upshur: 37:51

So the best source of information daily on the outbreak in my estimation, is a listserv called ProMED. It's the Program on Emerging Infectious Diseases. This was a listserv started by infectious disease specialists, public health specialists and viralologists in the early nineties, after the Institute of Medicine issued a report called Emerging and Reemerging Infectious Diseases, which is the blueprint- this event that we're living has been predicted by experts for quite some time. So they started ProMED as a way of exchanging reliable information. So it's a moderated listserv. It provides a daily update on coronavirus. And when I was working in public health during SARS, ProMED was an absolute lifeline. And I've relied upon it heavily through H1N1 influenza, both Ebola outbreaks, and Zika because it's authoritative. So they had a report I think the day before- just in the last few days about there finally being a reliable antibody test. So there's lots of people out there saying,"Oh, we've got an antibody test." But as you know, lab work is finicky and you need it to be reliable. You need it to be valid. You need it to be scalable. So I think we're now just getting to the point where we're going to have reliable serology. Now that'll be important to- so we'll need to know what the acute and convalescent levels are, we'll need to know what counts as protective titers, but I think we're soon to have reliable blood tests. They're not there now. When we do- and I'm hoping they're doing this in Wuhan as we speak- you can go o ut in the community and actually calculate the denominator. We still do not know the true- as everybody says, we're seeing the tip of the iceberg in the overwhelmed hospital system, but we don't know what the community spread is like, and the only way we're g oing t o do that is through a random serology surveys. And then we can- I don't know if you saw t he thing by J ohn I oannidis- t here's no evidence underlying our response and we need to know the true case fatality rate and we need to know this, that, and the other thing. Of course, we need to know that- those are all priorities that we identified at the meeting in Geneva in February when w e w ere looking at research priorities. But if you don't have reliable a serology test, you can't get that information to calculate what the true case- the truth a fatality rates are. So I think that would be a very helpful tool to help us manage the outbreak a bit better.

Dr. Rezmovitz: 40:46

And so have you heard anything about- I'm just covering hot topics now- have you heard anything about chloroquine?

Dr. Upshur: 40:54

Yeah, so-

Dr. Rezmovitz: 40:56

Because all my friends are just drinking gin and tonic.

Dr. Upshur: 41:00

Don't. So the other working group I'm sitting on is the therapeutics working group, and there's another really good lesson here. So I'm gonna just- sorry if I go on for a long time- but remember back to Ebola. In August 2014- I think it was on August 12th, I was invited to a meeting by Margaret Chan who was then the director general. She convened a small group of people to ask and answer the question should we proceed with the fast tracking of the evaluation of therapeutic agents for Ebola virus disease. At that time, remember ZMapp? ZMapp had been tried in like six macaque monkeys. There were 20 treatment courses available in the world. There was some concern that there were- or some thought that there were repurposed antivirals that can be brought into to use this. So we said,"yes, let's fast track the evaluation." So we're going to basically hop over the usual animal preclinical phase one, phase two, phase three, and in a very structured, careful way, introduce these through a path that we called monitored emergency use into clinical trials. And then I chaired the working group on ethics and clinical trials for the World Health Organization. Fast forward. So what came out of this are what are called platform adaptive randomized trials. And so we went from a position in 2014 August where Ebola virus disease had 70% mortality, no known medical countermeasures, no drugs, no vaccines to August 2019, when we had a licensed vaccine and the reports from an adaptive platform clinical trial in the democratic Republic of Congo that showed that two monoclonal antibodies flipped the mortality curve from 70% fatality rate to 70% survival rate. And the only way we did that was through the rigorous testing and evaluation of therapeutics. Every clinician- you know this, Jeremy- everybody thinks this'll work, that'll work. And we knew early on in Ebola, people were sticking everything that they had and like repurpose-"maybe an antiretroviral will work." So I understand that physicians abhor therapeutic vacuum and trying something is better than nothing- that was Donald Trump's argument. But we really need rigorous assessment. And so the World Health Organization- the R&D blueprint- so the WHO is just the convening organization, but actually the NIH, Gates, Wellcome Trust- everybody's funding this- has a trial called the solidarity trial. It's a rapid- it's like a pragmatic, adaptive platform design and chloroquine is one of the arms. And because this is being fanned out globally, people sign onto the protocol, adapt it, put it in, we should be able to get answers within 28 days. And the beauty of an adaptive design is if something works, you keep it in. And if it works better than the standard of care, then the placebo arm drops out and now you have a multi armed comparative effectiveness trial. If something doesn't work, it gets kicked out. If a new candidate comes in, it kicks on- it's like a perpetual motion machine and it keeps going, and it can generate answers because the way that the solidarity trial is designed is a 28 day mortality endpoint. So simple clinical outcomes, clear inclusion, exclusion criteria, get an answer. And then you design- there's a lot more questions we need to answer, but rather than everybody going out and- what was it, that unfortunate person who saw chloroquine on a label for some sort of cleaning product and go-

Dr. Rezmovitz: 44:58

For the aquarium.

Dr. Upshur: 45:00

For the aquarium, like don't do that. So it's really hard to get people to believe and trust in science because it's not about faith. It's about reason. And we will get answers easier if we work together and mobilize the massive amount of research capacity we have globally. Because this- Sierra Leone, Guinea and Liberia are at the bottom of every development list. They have no functioning healthcare system. You know when they talk about flattening the curve and here's the health system capacity, their system capacity is the X axis, right? They got nothing and we managed to get a vaccine trial done. DRC has militias running around with machine guns and often shooting up healthcare facilities, but we got answers. We can do this if we put our minds to it.

Dr. Rezmovitz: 45:50

When did the trials start? Do you know?

Dr. Upshur: 45:52

Which one?

Dr. Rezmovitz: 45:53

Well, when's the 28 days off? Where do we-

Dr. Upshur: 45:55

So people are signing on- the protocol's approved. It should be up and running in systems around the world.

Dr. Rezmovitz: 46:03

Okay.

Dr. Upshur: 46:04

The EU had- so these platform trials are going off. The enemy is of course everybody doing- so China did 90 clinical trials, but there was no standardization. The randomization was often poorly described. They often through the kitchen sink. So it's[ inaudible] the first one of Cal Tara[?]- I think it's an HIV combination antiretroviral. They published in the New England Journal last week with kind of equivocal results and they were equivocal because the trial wasn't designed for- it was poorly designed. So I know I've been working with this working group- the people who are doing the design of this study are the best in the world, right? So let's go with the best.

Dr. Rezmovitz: 46:48

I agree. I feel like Donald Trump is a little like Jim Jones right now.

Dr. Upshur: 46:54

Yeah, yeah, yeah. Clarkman Koolaid. Yup.

Dr. Rezmovitz: 46:58

Right? Like, who the hell is drinking his Koolaid? I just don't get it. And the fact that he's telling people,"well, the cure might be worse than the"- what did he say? How did you frame it?

Dr. Upshur: 47:08

"The cure is worse than the disease."

Dr. Rezmovitz: 47:09

"The cure is worse than disease." Are you insane? Like this is just unbelievable that a world leader would put so many people at risk, especially the people that are going to listen to him, who would vote for him in the next election.

Dr. Upshur: 47:24

Exactly. So Jeremy, here's where the other half of my life comes into play. So my Canada Research Chair- half of it was working on all of these issues around pandemics. The other half was understanding multi morbidity in primary care. So we got a bit- I think we thought we had a sense of how the virus was going to behave in a system by using the Chinese example to inform our response. 80% generally well, 20% sick. Of that 20%, 5% require hospitalization, another proportion of that 5% require ICU and 2% die. Italy has contradicted that. And the reason is Italy- like Canada is a place where multi morbidity is the rule, not the exception. And we know this. All of the studies that I did on multi morbidity and all the things that Mark Tenforde's[?] done in primary care, the work of Laura Rosella and Walter Wodchis showing that in Ontario, the vast proportion of people 30 and above are getting- are multi morbid. And multi morbidity and aging in particular do not combine well with COVID.

Dr. Rezmovitz: 48:41

Do you think it has anything to do with a catecholamine burden that could exacerbate someone's illness? I'd read a study on the flu vaccine and that it lowered people's mortality rate who had comorbidities like heart disease. And the mechanism that they were proposing was that if you had the flu vaccine, you'd be at a less chance of activating the catecholamine cascade if you were to get the flu, which would then put pressure on the heart, right? And then if you're already having a heart disease, it would put you at risk for death, obviously. So I'm wondering if there's a similar method.[inaudible]

Dr. Upshur: 49:24

Yeah. So the immunology of this coronavirus is quite intricate and we're kind of learning on the fly. I haven't thought so much about cytokines and interleukins, and respiratory epithelium for a long time because I'm attending all of these therapeutics meetings where they're kicking around whether to use you know, this monoclonal antibody or this cytokine or interleukin and inhibitor or promoter. So we actually don't quite fully understand the immunopathology of the coronavirus yet, but man, people are working furiously on it.

Dr. Rezmovitz: 50:10

Okay. So I think we're almost out of time here, but I just want to put a bug in your ear regarding clinical public health and-

Dr. Upshur: 50:22

And you're a member of our division.

Dr. Rezmovitz: 50:24

I am, yeah. My challenge to you is, use us.

Dr. Upshur: 50:32

Yeah.

Dr. Rezmovitz: 50:33

Right. What's the best way? I mean, this podcast is called Small Changes, Big Impact, and if we've ever had a time for a small change and how we come together and collaborate to improve the health of our patients- help me. Like I challenge you and everyone listening to come up with a way that we can start making clinical public health a reality where we can integrate family medicine and public health. But I need something to operationalize. I need people like you who are way smarter than me. Probably like the third or fourth smartest person I've ever met, Ross.

Dr. Upshur: 51:16

You're very kind.

Dr. Rezmovitz: 51:16

Yeah. But you told me- I don't know if you remember- David Naylor. You told me once that David Naylor was the smartest person you've ever met.

Dr. Upshur: 51:23

I think so. Yeah.

Dr. Rezmovitz: 51:24

Yeah. And so then I spoke to David Naylor- he happened to be sitting in the waiting room and I came back to you afterwards and it turned out that both David and I had met Karl Skorecki,[inaudible] who was the smartest man he ever met. And I was like,"Oh yeah, Karl's pretty smart. That's pretty awesome." So, you know, you're up there. So I challenge smart people now to say,"listen, how can we mobilize?" What can we do as frontline- other than supporting our patients because we're always supporting our patients. We've got people who are on the front line volunteering for other positions that they can pick up at assessment centers. I'm sure there are people who are going down in the hospital as hospitalists and small community hospitals that can probably pick up shifts there. People who are working in the ED. This isn't just a generalized Toronto question. This is a bigger Ontario question right now. What else can we do as family doctors to help prevent this from getting worse? That's my challenge.

Dr. Upshur: 52:26

Yeah. So I think the small changes are changes that I had proposed a a couple of years ago that didn't go anywhere. And it was basically about reorganizing resources regionally to have people identified as liaisons between- or a set of practices and public health. So you would have information flow backwards and forwards.

Dr. Rezmovitz: 52:59

So I mean it might be a good time to start instituting faux[?] leads or fit leads.

Dr. Upshur: 53:05

Well, yeah-

Dr. Rezmovitz: 53:07

- to transmit information, right? Because we have those networks already set up.

Dr. Upshur: 53:12

So I'm going to put in a naked plug for a program that I administer, which is the- we now have an advanced standing MPH in the Dalla Lana School of Public Health for Family and Community Medicine- a one year MPH. And I invite people to take- to come if you're interested, if you've been stimulated by or horrified by what you've seen happen, we need family physicians to come in, get that public health training and then work with- remember most- I also administer the Public Health Preventive Medicine Residency Program. All of them take their- they do their CCFB, become card-carrying family physicians before they go off to become- do their public health training- become medical officers. We have the human resources. We need to organize them and connect them. And that's what I was- I'd been- I'm not going to say who I talked to about proposals about building up this network. There are many public health physicians who may or may not want to work as medical officers. That might want to be kind of what in the triple aim we call integrators- people who- because public health physicians are the only physicians who get epi biostats health systems training as a requirement for their exams. And you know, you come from a family physician, you understand, you got your creds- you understand, you know what a family physician does, then you'd understand what a public health physician does, understand population health. So you've got a pyramid that goes from blanket coverage of family practices. You have leads who have taken- they may or may not have an MPH. And you've got these specialists, just like we use cardiologists, right? And then we have a system where part and whole were connections and information. And then all- I'm so happy to hear that you're a Sentinel surveillance physician. We should be doing that for a variety- you know, Sipson is one for chronic disease. We've got them for influenza, but we need to equip family physicians with public health tools so that they have real time information that informs clinical decision making. We can do this.

Dr. Rezmovitz: 55:25

So I'm willing to accept your challenge. I know it sounds crazy because I already have two masters, but what's the third?

Dr. Upshur: 55:33

Hey, you know me, there's no ceiling to education.

Dr. Rezmovitz: 55:36

Right. What's a third? No, I'm really considering this. So I would like to know more. If there's any way you can, send us the link because I'm going to argue that- and maybe this is the point that we need to kind of end on- is that I would love your best, nostradamic take- I turned it into an adjective there. Prognosticate for us. Because combining your challenge of picking up an MPH, and I'm going to challenge you to turn it into a distance learning opportunity.

Dr. Upshur: 56:15

Would love to. Absolutely.

Dr. Rezmovitz: 56:17

And then combine that with the prognostics of how long do you think we are going to be like this? In this current situation? I don't think it's two weeks like Trump is saying.

Dr. Upshur: 56:30

No, the best case scenario is- so if you look at the Wuhan data, they put the lockdown on the 23rd of January plus/minus a couple of days. They had four days with no cases. You can't declare an outbreak over until you have two incubation periods with no click cases. So that's 28 days. Now the big question is- and I'll send you this really excellent, they call it the hammer and the dance. You need to hit it really hard with a lockdown. And then once you've bent the curve down- and part of the bending the curve isn't the one that everybody's looking at because the area under the flattened curve is the same as this curve, right? So you're not really gaining anything. You're just pushing it all into primary care where you don't have any swabs or personal protective equipment, which makes no sense. And I've been arguing strenuously that there is a kind of incoherence to this flat- if the flattening of the curve is saving the hospital system, it's not saving the healthcare system because it's putting the onus entirely on primary care.

Dr. Rezmovitz: 57:30

That's the first rule of thermodynamics- energy not being created or destroyed.

Dr. Upshur: 57:35

Yes, exactly. So best case scenario is that we get this under control in six to eight weeks. Worst case scenario I think is the Imperial College model that spreads it out to 18 months.

Dr. Rezmovitz: 57:52

You're saying that I could have an MPH in those 18 months?

Dr. Upshur: 57:56

You could- I'm actually gonna go harass my Dean now.

Dr. Rezmovitz: 57:59

Okay.

Dr. Upshur: 58:00

Yeah.

Dr. Rezmovitz: 58:01

Is that- who's the Dean of-

Dr. Upshur: 58:03

Steinni Brown.

Dr. Rezmovitz: 58:04

Yes. Okay, great. Let me know when I can start matriculating and[ inaudible].

Dr. Upshur: 58:10

Well, you know, if this podcast generates interest, I will- because we now we're going to have a kind of companion division and in our own Department of Family and Community Medicine, I would be more than happy to use my time and energy to build that strength and capacity. Yeah, absolutely.

Dr. Rezmovitz: 58:32

Yes. Listen, do you need a first follower for movement? Have you seen that video?

Dr. Upshur: 58:38

No, I haven't.

Dr. Rezmovitz: 58:40

No, you haven't seen the- after this is done, Google first follower.

Dr. Upshur: 58:44

All right.

Dr. Rezmovitz: 58:45

Actually you could probably just Google it right now. I don't know if you're on the- let's see if that's what it is. First foll- I want to make sure you get the right. First follower video. Oh yeah, just type in first follower video.

Dr. Upshur: 58:59

Okay.

Dr. Rezmovitz: 58:59

Okay. Let me be your first follower.

Dr. Upshur: 59:02

Alright.

Dr. Rezmovitz: 59:03

All we need is a second follower for a movement.

Dr. Upshur: 59:06

Yeah. Okay. Well we've got 10- I mean the course I'm teaching now has eight family physicians in it.

Dr. Rezmovitz: 59:11

Oh, so you're already doing this. This is what[inaudible].

Dr. Upshur: 59:13

I did. So I did the- we have the advanced standing in now in the first class is going to be graduating and the first class- I'll let them speak- they might be- they might have a different view, but I think they found the course that I gave rather applicable because when we did the history of public health, it was all about ancient plagues and pestilences and quarantine and then boom- coronavirus hits, and virtually everything we were talking about came to life. So I do just want to remind people- and I've alluded to this already- since 2003, three coronavirus outbreaks, two Ebola, one H1N1 influenza pandemic, and the destroyer of destination weddings: Zika. Seven major infectious disease outbreaks, four of which were declared public health emergencies of international concern in 17 years. We will get through this and then we will have another.

Dr. Rezmovitz: 1:00:13

Yes.

Dr. Upshur: 1:00:13

So let's get our act together. No excuses after this one because this has been truly global.

Dr. Rezmovitz: 1:00:21

I'm going to have to respectfully disagree with you because there will be excuses after this one.

Dr. Upshur: 1:00:28

Of course there will. And we're going to learn lessons cause it's a wake up call.

Dr. Rezmovitz: 1:00:34

It's a wake up call. Okay Ross, thank you so much.

Dr. Upshur: 1:00:37

I hope this is useful. Yup.

Dr. Rezmovitz: 1:00:39

Yeah. I hope to get the link for the MPH from you. Maybe[ inaudible] will start waking up and being like,"maybe we need more training on how to deal with this stuff." If we can mobilize more people and train them from a public health standpoint, then maybe we can actually start developing a system.

Dr. Upshur: 1:00:55

I agree. You know, even at my late age I still remain hopeful.

Dr. Rezmovitz: 1:01:02

Passionate.

Dr. Upshur: 1:01:03

Passionate. Yeah. Yeah. I love it. I still give a damn.

Dr. Rezmovitz: 1:01:08

Me too.

Dr. Upshur: 1:01:09

Yeah.

Dr. Rezmovitz: 1:01:09

Alright, thank you again and[inaudible].

Dr. Upshur: 1:01:12

I'll send you the link also to that really instructive modeling exercise.

Dr. Rezmovitz: 1:01:19

Okay, great. Thanks.

Dr. Upshur: 1:01:21

Thank you. Thank you. Take care well. Keep well, keep sane.

Dr. Rezmovitz: 1:01:24

You too. Bye.

Dr. Upshur: 1:01:24

Bye.

Dr. Rezmovitz: 1:01:28

This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Alison Mellon, Ryan's cell phone and the whole podcast committee. Thanks for tuning in. See you next time.