The Pandemic and Dance: A Physician’s Perspective

At the onset of the pandemic, we reached out to an amazing practising physician who provided her insights about COVID-19 and its potential interactions with the dance community. As time has worn on, many of us have done the responsible thing by following local health guidelines.

But, for many, there are still many questions. Questions I am in no way qualified to answer – but a physician can. So, here are some of the questions I’ve heard in the last few months, along with Dr. Hsu’s responses (as well as my own commentary, where indicated).

“I’m reading a lot of things online that are making me question whether it’s that big a deal. Are these things correct? What’s a good way of making sure I’m getting good info?”

Dr. Hsu: This is really a question about epistemology – the study of knowledge acquisition. The Dancing Grapevine actually has a good post about this (note from TDG: read it the whole way through).

In a nutshell: we don’t have enough time, opportunity, and ability to experience and test every hypothesis about the world. Instead, we rely on people and institutions we trust to tell us their perspective.

This means that the credibility of the source and delivery medium matter. Some of the delivery mediums include  traditional media, social media, academia, and government public health sources. Depending on where you are in the world, the reliability of each of these sources may vary.

In general, your local public health authority is likely a reliable source. They have a vested interest in the health of your community and are likely run by individuals with public health training. This means they dedicate their lives to improving population health.

Social media is a popular way to share information, but is highly subject to bias and unverified information. If you look for information on social media, consider reputable people who have a background in virology, epidemiology, public health, or physicians in the field with actual experience dealing with various aspects of COVID-19. Those whose epidemiological background is non-existent before March 2020 are not likely the best source of information. It is also a good idea to investigate any possible conflicts of interest.

Traditional media can also be subject to sensationalism and bias as well. However, at a certain point, if most traditional media sources, academia (scientific institutions), and reputable people with experience are all saying there is a problem, there is likely a problem.

TDG Note: Please remember that one seemingly “legit” voice does not make a fact true. In fact, even several dissenting voices do not make something “true”. In the context of an entire profession, even 1,000 verified names is a small drop in the bucket of the entire profession as a whole. For example, in Ontario (one province with a population of 14.5 million), there are over 40,000 licensed physicians. This does not include non-physician scientists, nurses, and other health professionals. The presence of a dissenting voice does not make it accurate – even with qualifications. There’s a reason that on some matters, there is a larger scientific consensus.

Also, be careful with data. The vast majority of us (including myself) are woefully unprepared to actually understand its implications. And, it’s really easy for people we are relying on to have gotten it wrong as well.

“I don’t know anything about scientific research or data, but I see a lot of graphs that say this isn’t a big deal or give conflicting reports about data. What are some basics that I can use to help me understand what’s going on and identify good data or research studies?”

TDG: Here’s a great podcast on the impact of trusting sources

Yes, COVID is a big deal. Countries all around the world do not drastically change behaviours for no reason. Further, countries are not organized enough to create a massive global conspiracy. Think about it: they can’t even agree on the little things.

If you want a book to help you understand things more deeply, “The Rules of Contagion” by Adam Kucharski, PhD mathematician at London School of Tropical Medicine and Hygiene, who built his career on infectious disease epidemiology, is excellent and easy to read.

I will try to explain why this is a big deal and the basics you can use to understand what is going on, but be forewarned: it’s a lot of mathematics.

TLDR: Refrigerated trucks outside hospitals to pick up dead bodies because the morgues have exceeded capacity seem like a pretty big deal.

History of Pandemics

Pandemics have impacted and altered human society throughout human history. More recent ones documented, including the medieval Black Death, smallpox in North America, and the Spanish Flu of 1918-19. In these cases, there is a novel infectious source that no one in the population has immunity against. This means everyone is at risk of infection. Humans then (try to) adjust their behaviours to reduce transmission in response. This is beneficial for collective survival. Efforts are well documented, even if some approaches were limited by the knowledge of the time.

Now, we enter a question of mathematics and scale. When you take a global population of 7 billion when there is almost universal susceptibility(or even a theoretical country/city population of 10 million), the potential for harm is significant.

The most obvious impacts of the virus are:

• Mortality (deaths)
• Morbidity (long term health consequences)
• Long-term mental consequences for seriously ill patients and their families
• Healthcare system capacity
• Mental and physical health of healthcare workers, and their loved ones.

The long-term impact of many of these things is yet to reveal itself.

The economic and psychological impact of measures taken to reduce spread are also significant. However, it is worth noting that the comparison group for these impacts should be an uncontrolled pandemic – not life in 2019. While tempting to compare our current state to what life was, it is not accurate.

Regardless of how “small” the mortality rate might be, when you multiply that by enough infected people, it becomes significant. Even .5% of 10 million is 50,000 extra deaths that would not have occurred. It is also now clear that COVID disproportionately affects vulnerable and traditionally disadvantaged groups including:

• Seniors
• People with disabilities
• People with chronic health conditions (a large portion of the population), and,
• People of colour, who disproportionately occupy essential, lower-income jobs that are difficult to do from home (in Canada, at least).

This means that there is also a component of equity to be considered in the response as well. It is also worth noting that a not-insignificant number of young people and people with no pre-existing conditions can and have died, become seriously ill and/or experience long-term health impacts from the virus. This virus goes beyond “only impacting old and sick people.”

Reading Research Papers

If you’re going to try to read medical research papers and do not have the training to do so, understand that you probably won’t understand the nuances and implicit information. That’s ok.

I don’t try to read engineering research papers because I have no training in that field and do not understand the paper’s assumptions nor do I have background knowledge to inform my understanding. I can try to read papers in laboratory/molecular medicine but with great difficulty because, again, I do not have significant training or experience in it.

I feel fairly confident in my ability to parse out the information in clinical trial research papers, including understanding their strengths and limitations, but that took many years of studying in a relevant field with additional specific research methodology education.

It’s important for us as humans to acknowledge the limits of our knowledge. We can be humble and curious and try to learn more, but it’s important to not assume the expert role in the process. With that in mind, here are some basics to help you understand some of the language:

Commonly referenced language:

• IFR = infection fatality rate = number of deaths divided by number of infected individuals in a population
• CFR = case fatality rate = number of deaths divided by number of diagnosed infected individuals in a population
• Attack rate = number of people who end up infected in a group of susceptible people (This is high for SARS-CoV2)
• R0 (pronounced-naught) = the transmissibility of the virus, on average, assuming no modifications are in place and in a susceptible population.
• Rt = current transmission rate based on real-time data. This number changes based on policies and our collective action.
• K = dispersion parameter

Testing Capacity

Testing capacity in a given location can impact the number of diagnosed individuals, not the actual rate of infected (until we use the number of diagnosed infections to modify our behaviour). For example, if you are pregnant, you may not have a positive pregnancy test because you didn’t pee on a stick, but you are still pregnant. The same goes for COVID: those infected that have not been tested aren’t counted.

Further, tests do have false negative rates. PCR, the test when they put a stick up your nose/throat to find viral genetic material, can be falsely negative fairly frequently – but is rarely falsely positive. In general, false-positives for the PCR test are not an issue. 

Understanding Attack Rate

COVID is a novel pathogen. We have been able to study it in cruise ship, weddings, jail, and other outbreaks where large groups of people were in close proximity for long periods of time. In those situations, an attack rate of 80-90% has been observed. This means that COVID has a high attack rate, and contrary to the “T-cell immunity” arguments: most people are not already immune.

Understanding Ro and Rt

Ro is our general understanding of how transmissible a virus is. SARS-CoV2 has a suspected Ro of 2-3 based on transmission observed in early Spring. That means every infected person, on average, spreads to 2-3 people, and each of those, spread to 2-3 more. This causes exponential growth.

Rt is about the current transmission rate. This differs slightly from Ro as it has to do with how things are currently progressing in a specific area.

When R (Transmissibility of the virus) is > 1, an epidemic is growing exponentially.

When R = 1, each case infects one other person and the epidemic will continue to grow at the current infection, so if R hits 1 at 100 cases per day, it will continue at 100 cases per day; if it hits 1 at 1000 cases per day, the next day will still be more 1000 cases.

When R < 1, each case infects less than one other person on average and the epidemic eventually dies out

Remember that the epidemic is growing exponentially whenever R > 1. This means we have to work against our own intuition. Our brains are wired to understand linear (constant) growth much better than exponential.

Imagine you are crossing the street and a car is coming towards you at constant speed, versus if that driver presses the gas and they are approaching you with acceleration. Responding as if the car is coming at you with linear constant speed when it is accelerating towards you will increase your risk of harm significantly.

We are the pedestrian, exponential COVID growth with R >1 is the accelerating car.

Virus Variations

You may have heard about the new dominant COVID variant sequenced in the UK: B.1.1.7. It is important to note that viruses mutate all the time. Each time they replicate, there is a chance of a “mutation.” Usually, these mutations do not lead to any significant changes that impact people.

Overall, SARS-CoV2 is a fairly big virus that stayed remarkably stable and consistent for many months. Unfortunately, with widespread transmission and more viral replication, there are a couple of early 2021 variants that are concerning. We currently have more information about B.1.1.7.

Early estimates suggest it could be up to 50% more transmissible. Mathematically, a higher transmissibility is actually more concerning for population mortality than a 50% greater fatality rate.

This has to do with the R. Credit to Adam Kucharski for the following illustrative example:

“If the current Rt=1.1, and we estimate infection fatality risk as 0.8%, with generation time of 6 days, and 10k people currently actively infected (plausible for many European cities recently), we’d expect 10000 x 1.1^5 x 0.8% = 129 eventual new fatalities after a month of spread.”

What happens if fatality risk increases by 50%? By above, we’d expect 10000 x 1.1^5 x (0.8% x 1.5) = 193 new fatalities. Now suppose transmissibility increases by 50%. By above, we’d expect 10000 x (1.1 x 1.5)^5 x 0.8% = 978 eventual new fatalities after a month of spread.

This increase of transmissibility matters incredibly at this time. Vaccines are on the horizon. Behaviours that were perhaps an “acceptable risk” previously, may not be now. We are tired, and people become complacent when tired. Please try to view new information with fresh eyes, and adapt behaviour accordingly.

From TDG: There is a mobile game called Plague Inc. For a non-sciencey way of understanding why a more infectious virus is more concerning than a highly fatal one, try playing with mutations and evolutions in the game. You’ll quickly find out viruses can basically kill themselves off if the fatality rate is too high in contrast to its spread rate. Obviously, higher rates of death are terrible and scary – but don’t underestimate the amount of damage a less-lethal virus can do if it isn’t stopped from spreading. 

Understanding K

K = dispersion parameter. This is used to account for the fact that most COVID cases are caused by a small number of infected individuals, and most people who are infected do not infect anyone else, or infect only a small number of individuals.

Data supports that SARS-CoV2 is driven significantly by “superspreading” events. Japan has had success keeping their society mostly open by specifically targeting superspreading events, and the environments which make it more likely.

This is relevant to social dancing because social dances ave a high potential to be superspreading events. They involve people in close physical contact, breathing heavily in the same air, for prolonged periods of time.

“Why do scientists, doctors, and public health professionals seem to disagree on things or change their approach from time to time? Doesn’t this mean that they don’t know what we’re doing and we should be skeptical?”

The Novel Coronavirus is new, as the name suggests. When it began in late 2019, no one knew anything about it. We are building the plane as we fly it.

Science as a field is about acquisition of knowledge through testing of different hypotheses. We draw independent conclusions based on all available evidence, and change our conclusions when new information suggests it is prudent. It has worked like this for centuries. The pandemic has accelerated this process, and knowledge about SARS-CoV2 is being acquired at incredible speed. I imagine it’s jarring for people without a science background to view this happening in real-time.

Disagreements in science are healthy and a part of the process. Eventually, we oscillate towards an agreement. Even then, there will be some variability within the consensus. This is all a part of the scientific process.

Just remember: changing your conclusion in the face of new evidence is science. Starting from a conclusion and looking for evidence that supports it is ideology.

“What is the difference between a public health official, a doctor, and a general scientist? I see some doctors and scientists saying it’s not a big deal.”

Public health is the study of health for a population, with focuses on prevention and health promotion. People who work in public health may be medical doctors or come from a different background, but they have extensive training in studying health across a large group of people.

A medical doctor studies diseases, diagnoses, treatments, and applies their knowledge to treat individuals. From a scholastic perspective, it is someone who has an MD degree.

Note from TDG: An MD does not mean someone is licensed to provide medical services – this is usually done through a College of Physicians or other organization. Depending where you are from, the qualifications and education required to be a licensed, practising physician may vary. For example, some places license naturopaths or chiropractors the same way they license MDs. Some have a separate process for these groups. Some do not recognize these groups as a practising physician at all, and may not even regulate these fields. 

A general scientist can be from many fields. They gather data from different sources through different methods and try to synthesize the information, test hypotheses, and draw independent conclusions.

Despite the greater scientific consensus that climate change is a big deal and the challenge of our lifetimes, there are still scientists which deny its existence. This is similar to how most doctors and scientists agree that the COVID pandemic is a problem.

If 97% (theoretical percentage) of scientists agree there is a problem, it’s strange to focus on the 3%. There are varying approaches on management, but the starting point of agreement is that there is a problem.

Note from TDG: Ontario alone has over 30,000 physicians licensed to practise medicine. This means that 3% of that number would be 900. If we apply this to even larger numbers (for example, all healthcare providers, all physicians in North America, all scientists) it becomes clear that even having 5,000 dissenting voices is still a rather small number when it comes to trusting the word of a few over the many. This might be a good thing to think about the next time someone claims that “thousands” of professionals disagree, and that this somehow means there is a large percentage of dissent.

“Some people say that things aren’t that bad. You’re a doctor. What have you seen? How has it changed your work?”

COVID pandemic has changed my work immensely, from small mundane ways to big ones.

A daily change is that I have to wear a mask for the entire time I am at work. Eating and drinking is difficult as we need to find a private place to remove our masks, which means I go through daily involuntary intermittent fasting (I really liked snacking in the “before” times). I also see a large increase in my patients’ now-profound loneliness in hospitals while recovering from illness, as they are not allowed visitors nor to leave the grounds.

I have seen the morbidity caused by COVID. I have seen strokes causing paralysis and persistent neurological deficits causing an inability to walk. I have seen persistent difficulty breathing, where regular activities like walking upstairs is challenging.

I have also seen psychological trauma from intensive care unit stays. For example, imagine being partially sedated, a tube in your throat that you cannot pull out because you are paralyzed, and not being able to speak or ask for help. Imagine being only partially awake, confused, with shadowy figures in gowns towering over you.

I do not work in intensive care, but I believe the tears of my colleagues when they speak about holding up video phones to let patients see their loved ones, possibly for the last time, prior to intubating them (when we put a tube down your throat and link up to machine to help you breathe).

I believe the terror in having your entire intensive care unit filled with COVID patients, and having to choose who gets treatment, and knowing that many other people who need treatment for other reasons may not be getting the care they need as we grapple with this crisis.

“Are temperature checks adequate to make sure people don’t have COVID-19?”

Short answer: No.

Long answer: No, because there can be so many false negatives. For example:

• How are you taking the temperature check? Forehead thermometers are unreliable.
• How are you defining a “fever”? Many COVID cases have “low-grade” fevers, or none at all. Many cases have fever only at some part of their disease course, but not throughout.

We cannot see into the future. People are most infectious right before they get symptoms. You have no way of knowing if the person in front of you is infected if they are asymptomatic or have no fever.

“I went to a gym that doesn’t require masks and I’m fine. So, why can’t we hold dance socials?”

Gyms still cause outbreaks. They are a higher-risk environment as it is enclosed with people breathing heavily. Even with this in mind, you’re probably not putting your face next to another person’s face at the gym; you are in social dancing.

We also need to keep in mind that population risk is different from individual outcomes. Indoor gyms are a higher-risk environment and social dancing is a high-risk activity. The fact that some individuals won’t get infected does not negate the risk potential.

“What things should I see in my area before it is safe to hold a local social or class?”

Again, “safe” doesn’t exist, only safer. Ideally:

• a Rt much less than 1
• < 1 active COVID case per 100,000 people in a population
• Test % positivity is < 1% (number of positive tests in a day, divided by number of tests done that day) and your area has adequate disease surveillance with robust testing, contact tracing, and case isolation mechanisms, without significant outbreaks or strained hospital resources. This is significant because a high positive % indicates a high likelihood that there are many more cases int he community that are being missed.

Even then, people move around and cases can change quickly. If you are in New Zealand or Taiwan in late 2020, you can likely do whatever you’d like. Everyone in North America/Europe with significant community transmission, even if where you are meets these thresholds, likely still needs to have classes with some behavioural modifications.

Social dancing with partner switching would significantly increase risk of transmission as it is increasing the number of contacts. Therefore, unless you are in a place that has basically eliminated the virus, it’s not a good idea.

“My area is allowing classes. What precautions can I take to make sure they’re safer?”

Outdoors is much safer than indoors. You should also wear  a mask to reduce the stuff coming out of your nose/mouth from getting breathed in by other people. Lastly, you should reduce the number of people you dance with, acknowledging that you have no control over who they dance with or who they see on a regular basis.

“If I use fans and open windows, is it safe to host my social/class inside?”

“Are indoor classes and socials safe if everyone wears a mask, checks temperature, and doesn’t switch partners?”

“Are in-person private classes safe?”

“Are outdoor socials safe?”

Risk is cumulative and relative. There is no safe, only safer. Whether it is an acceptable degree of “safe” to have a class or social depends on the transmissions in your area, your local public health and hospital’s ability to handle the current infections, and the individual risk tolerance of your attendees. See the colour-coded figure below.

Figure from: Jones Nicholas R, Qureshi Zeshan U, TempleRobert J, Larwood Jessica P J, Greenhalgh Trisha, Bourouiba Lydia et al. Two metres or one: what is the evidence for physical distancing in covid-19? BMJ 2020; 370 :m3223

Outdoor is definitely safer than indoors. Opening windows is a good idea to improve ventilation; it is unknown whether that will make a significant enough difference to the litres of fresh air per minute brought into the room. This depends on the weather, size of the window, size of the room, and number of people breathing in the room.

The benefit of fans unclear. While it may increase circulation of outdoor air, it may also increase circulation of virus-ridden air.

If everyone wears a mask and maintains only one dance partner, that would reduce the risk. Likewise, a private class with one partner with whom you have close contact and a socially-distanced instructor is also less risky. But, if an instructor is having in-person private classes with multiple people, then their risk of infection increases, and they risk infecting multiple people.

Temperature and symptom screening should be mandated everywhere. It is a bare minimum to ask symptomatic individuals to not partake, acknowledging that it is in itself, not sufficient to guarantee safety, due to asymptomatic/pre-symptomatic spread.

“I really want to practice dancing. How can I practice safely if I don’t live with a partner?”

Now is a great time to work on solo dancing. It will improve your balance and technique, and help you tune in to your own body. If you really want to partner dance, see if you can find someone in your vicinity who consents to being your (monogamous) dance partner while we are in the pandemic. Of course, you can change this partner, but consider a strict 2-week quarantine prior to engaging with a new person. Testing has a high rate of false negatives and is not a replacement for physical distancing and quarantine.

When do you think events will be able to happen?

I am not a fortune-teller. Speculatively and optimistically, vaccinations will be given throughout 2021, and maybe later part of 2021 can have some smaller events in places where wide vaccination have occurred. Massive dance events like we used to see with people traveling internationally and face-rolling on hundreds of random strangers over a weekend will probably be relegated to 2022 or later.

Here’s a hypothetical dance scenario to explain those timelines:

• Dance congress with 1000 participants.
• Attack rate of 85% as dance congress is as high-risk superspreading as we can get
• 850 infected and need to miss work and isolate for 2 weeks, perhaps requiring their entire household to quarantine as well.
• If 10% have significant a morbidity that’s 85 people who may not be able to work or live healthily for weeks to months, or longer. Some of them may require hospitalization.
• Low-end of average IFR estimate at 0.5%, means 4 deaths.

This is assuming the 850 people somehow do not infect others, which is unlikely.

For a real-life scenario: a 55-person wedding in Maine led to 177 cases, 7 hospitalizations and 7 deaths. The people who died were not at the wedding; they caught it from people who were.

“The lack of dance and community has really impacted my mental health. Do you have any suggestions?”

I also work in mental health and substance use. I empathize with the mental health challenges brought on by the pandemic and its required restrictions. I think we have all been impacted by the pandemic in many ways.

Mental health has two components – external factors (which are mostly not in our control), and internal resources (which are in our control). These components are not fixed. We can build from the basics; for example, here are some well-supported methods to maintain well-being:

• Eating a healthy diet regularly, including minimally processed fruits and vegetables
• Sleeping well, for however many hours your body needs, on the same schedule. Look up “sleep hygiene habits” if you’re new to the term; this can help.
• Regular exercise – indoor, outdoor; whatever you can actually manage to get the energy to do that is safe in the current climate.
• Not using substances as a coping strategy. In particular, watch for the glorification of alcohol as a coping mechanism and self-monitor your intake.

Other ways of improving mental health include reaching out to communities virtually and maintaining social connections despite not being able to see people in person.

Mindfulness is a practice that I encourage everyone to check out. It helps us bring our awareness to the present moment and work on accepting whatever we are feeling/experiencing, without judgment. There is a focus on self-compassion, and empathy for those around us and for the world. This is another way of gaining internal resources.

Note from TDG: If you are in crisis, please do not delay getting help. Here are some resources:

• Ontario: https://www.camh.ca/en/health-info/crisis-resources
• US, UK, and Ireland: https://www.crisistextline.org/
• Worldwide list: https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines
• General Hotlines: http://www.pleaselive.org/hotlines/

We are living in a time of uncertainty. That alone is anxiety-provoking. Humans like to plan and dream about their future. It is normal to have some internal resistance to the fact that we cannot do that right now. However, we must accept this to move forward.

A way I look at it is that pain + resistance = suffering. Pain is inevitable in life, suffering is optional. When we reduce our resistance to accepting things as they are, we can better see what is actually in our control. We can still try to be grateful for what we do have. I recommend a daily gratitude practice as another method of gaining internal resources. Now more than ever, we need to be thoughtful, compassionate, kind, and focused on the greater good.