Compassionate Caution

Rejected by the New York Times, Washington Post, The Hill in March , 2020. Not edited since.

Allison Krug, MPH, is a data analyst and medical writer, military spouse and mother of two teen boys living in Yokosuka, Japan. They have traveled more than 60,000km in Japan’s oldest Toyota Estima to ice hockey rinks perched on caldera in the Japanese Alps.

Emerging Diseases Can Bring us Closer — in a good way

More compassionate caution and ingenuity, not cold clinical case counts

The ominous text from my running buddy punctured my calm, rational curiosity about COVID-19. “I’m not feeling well. No fever and I am sure it’s nothing but I am coughing, sore and a bit achy.” At that moment, the outbreak hit home in a way that it hadn’t yet in 8 weeks of vigilance. My family lives in Japan, about an hour from Tokyo. 

The virus is here, and we have adapted. But like all ex-patriate families, we are concerned about our stateside friends and family. Our kids’ grandparents are in California, New York, and New Jersey. How should I convince my parents to be smart without being accused of “fear-mongering”? As a mother of two teen boys, I get not taking advice from one’s parents. But the elders among us are sometimes not inclined to heed advice from their own kids, either. Maybe they have a point.

I wasn’t about to give up, though. I tried the same ingenuity that parents employ to manage their teens by suggesting that my mom explore the possibility of drive-in church services. This seems like something a Southern California super-church could pull off handily. Time and data will also help. The older set remains optimistic, signing up for hikes, and planning visits to grandchildren. Maybe they know what the case histories will tell us: that this cold virus can linger, making young adults feel off for weeks, and be a far more serious concern for others.

Shrine in Wakura Onsen, Japan.

和みの丘公園

Out for an early morning jog before the pressing humidity of August sapped me of the will to move, the scent of smoke drew me into the bamboo forest near a shrine tucked into a hillside. It wasn’t quite the same scent as incense, which I associate with temples. Up the hill over dirt stairs, I came around a bend was an older man sweeping up leaves with a traditional straw broom, a houki. He was tidying up the forest and burning leaf piles. The smoke created such beautiful komorebi (木漏れ日, sunlight filtered through leaves of a forest). Red flags like the one to the left lined the stairs. The darkness of the forest and the heavy scent of smoke nearly hijacked the morning plans, but I made it back in time for Japanese breakfast. Skipping showers and running late is justified by this find, right?

Trust and courtesy

Although I am trained as an epidemiologist and am thus fascinated by observing the progress of this epidemic, I had the same reflexes as most. When I first lived in Japan, seeing masks reminded me that disease is all around us. However, people here wear masks to stay healthy and be responsible. The fabric of this society is mutual trust and courtesy, an awareness that personal actions affect the common good. In fact, a common expression upon meeting for the first time, or asking a favor, is yoroshiku onegaishimasu, which essentially means: please take care of me.

Yet, despite our American frankness, it is with trepidation that we discuss our personal experience with infectious diseases. Right now, that’s the one thing we all want to know — what did it feel like? We want the case histories, the personal narratives. How did you know you should get tested? Did you get better, then worse again? On base as elsewhere, schools may close, neighbors may be in need. How can we respond in a way that respects privacy, yet acknowledges the reality of disease transmission? For other health conditions, like cancer and injuries, pop-up web donation sites enable financial support to pour in, but infectious diseases still carry an understandable silent stigma. The result is either shrinking from those in need, or over-compensating with blind stoicism, charging in and putting ourselves and our own families at risk by not social distancing when we should. I think there is a better approach: more data to describe the natural history of this new virus, and more compassionate language in public discourse.

Increasing testing will allow us to describe the symptoms across all levels of severity. This will help us protect each other. Understanding the continuum of illness will help calm markets, resuscitate travel and keep the most medically fragile safe. News reports of cases by age and underlying health conditions helps us contextualize our own relative risk according to emerging data. But the language we use shapes the public temperament, and certainly disclosing a name or place of worship should be out-of-bounds. I would like to suggest shifting the rhetoric to a more compassionate caution. Although officials are doing the right thing by being transparent, the intense focus on case counts, contacts, and presence of comorbidities dehumanizes.

Instead of: “A 48-year old woman with no underlying conditions just tested positive after shopping for groceries.” Try this: “A community member is experiencing the same symptoms many of you are sharing with us. She has an influenza-like-illness with dry cough, chills, irritated throat, runny nose and feels very tired. She has no friends or family with a positive test. She is at home recuperating.” (My best running buddy and I can’t wait for serology to confirm we’ve had COVID-19 already.)

As a public health professional, I am intensely curious, eager to describe and understand what is happening. There is a place for that in the scientific literature. The symptom charts are excellent ways to understand how the virus presents in different cohorts. As a mother and community member, I also think the public has a right to be informed, but I would suggest that we use a different way of speaking to reduce stigma and keep everyone healthy.

T-pose — the language of compassionate caution

Local leaders and managers need to model the language of compassionate caution. In Japanese towns, each block functions as a small village, with a village leader, the sonchō. We can organize homes and offices informally now to set up networks of support. A white flag or paper in the window can signal a family in quarantine. Neighbors can check for a note taped to the door with a list of needs. Parents can set up e-pay systems in advance with a network of healthy teen “runners” (who may need productive work if their school has closed) to shop for supplies. When we call in for food delivery, say: “I’m in quarantine so just to be safe, please put the food on the doorstep and ring the bell.” We can compare symptoms and commiserate, from a distance. Yesterday I modeled throwing my arms out and spun around for the neighbor kids to demo a meter radius. “Oh! The T-Pose!” they said, laughing. (I had to Google it.)

When I was sick, I soldiered through (wearing a mask), resolute, like many Americans. Later, it occurred to me that I might have had COVID-19 already. That shift in mindset — to the possibility that I had already survived this virus— made me far less concerned. I started scouring the literature for case histories among younger people. Recent open and frank conversation about symptoms with neighbors revealed four other mothers with the same thing! We don’t know if it is another coronavirus (after all, COVID-19 is in the same family as the coronaviruses which cause up to 30% of common colds). The point is, sharing information and support is part of being compassionate. Our communities can pull together to fight this and save lives.

Spring is a time of hope in Japan. The cherry blossoms signal that new life is emerging, and that warmth is coming. Nations have come together to rapidly sequence the genome of this novel visitor. More than a dozen vaccines are underway. New therapies are being tried, over 50,000 people are recovering, and research is exploding into the collaborative space. Parents and children are working and going to school, sometimes from home. Communities can take this time to rest, and renew trust and courtesy. With all of the good things happening, I hope that emerging infectious diseases will carry with them a concomitant social unity in spirit, despite the necessary social distancing.

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