“Hope is not a strategy”

Do you like rollercoasters? My first five years of life were the epitome of privilege and comfort in Uganda, and then within days my parents and I were on a plane to Montreal as refugees. The ensuing years were tumultuous. I remember living in attics, visiting the Salvation Army for clothes, and drinking the mini half and half singles for breakfast. We eventually settled in a small northern city, and my parents re-invented themselves several times over. During the summers, my parents would pack us up and we would drive across  Canada and the US – always stopping to visit the most extreme theme parks. My dad loved to take us on all the craziest roller coasters. Something my father said has resonated often during these past few months … “just enjoy the ride.”

The past few months have certainly felt like a rollercoaster to me: overwhelmed health care systems, cities and nations on lock-down, collapsing stock markets, unprecedented capriciousness and pandemonium from our political leaders. VUCA. First coined in 1987 by the US Army War College¹ to describe the post-Cold-War world, and based on the leadership theories of Warren Bennis and Burt Nanus,² this acronym is applicable now more than ever.^3,4 

Volatile, Uncertain, Complex, and Ambiguous.

Volatility: the accelerating rate of change, uncertainty: the lack of predictability, complexity: the interconnectedness, of cause-and-effect forces, and ambiguity: the strong potential for misreads. These four terms are interrelated; it is harder to predict a health outcome, the more volatile, uncertain, vague and complex the event. Case in point: SARS CoV-2.

“I would not give a fig for the simplicity this side of complexity, but I would give my life for the simplicity on the other side of complexity.”

– Oliver Wendell Holmes

The antidote to this is…

…VUCA: Vision, Understanding, Clarity, and Agility. This week’s PROspective article by Jake Wood, CEO and Co-founder of Team Rubicon, illustrates the two faces of VUCA, specific to the COVID-19 pandemic.

For public health professionals, consider this an opportunity to cultivate a growth mindset which will be translatable across multiple scenarios and situations in your professional and personal life. Take some time to hone (or develop) your personal guideposts which will provide the vision and strategy to ground you when the next VUCA situation takes place.⁵ You would fare exceptionally well by starting with the core tenets of our Epidemiology department: integrity, rigor, ambition, and collegiality. Cultivate how to be responsive and not reactive to the next crisis that you will inevitably be faced with.

“Hope is not a strategy”

– Jake Wood

How will you identify and reduce the impact of volatility, uncertainty, complexity and ambiguity when faced with challenges?

Here are some suggestions from an article in NEJM Catalyst, on “Responding to Covid-19: Lessons from Management Research”:

1) Put people first

2) Manage operations creatively

3) Attend to teamwork and communication

4) Create outside partnerships

5) Embrace clear and humble leadership

As an aside, these have all been very much in practice at RSPH during the past few months.

So, are you enjoying this ride? You don’t have any choice but to be right where you are, in the middle of a pandemic so you might as well just surrender to the ride. The lows will amplify the highs and the turns will be confusing, but they will all provide opportunities to learn and grow.

References:

1. U.S. Army Heritage and Education Center (February 16, 2018). “Who first originated the term VUCA (Volatility, Uncertainty, Complexity and Ambiguity)?”. USAHEC Ask Us a Question. The United States Army War College. Retrieved July 10, 2018.
2. Bennis, Warren; Nanus, Burt (1985). Leaders: Strategies for Taking Charge.
3. https://www.forbes.com/sites/davidmichels/2020/05/10/for-leaders-the-lessons-of-covid-19-go-beyond-crisis-management/#23050c927e9b
4. https://chiefexecutive.net/understanding-vuca-environment/
5. https://www.ckju.net/en/blog/strategic-management-how-and-why-redefine-organizational-strategy-todays-vuca-world/58699

RETROspective

As the semester comes to a close, we wanted to take a look back at some of our favorite PROspectives over the last few months. As the COVID situation developed from an isolated outbreak to a full-blown pandemic, we have gotten insights from faculty, staff, and alumni on topics both pandemic and non-pandemic related. Here are some of our favorite articles from Spring 2020:

1. In Keep Calm and…, Dr. Timothy Lash started off the semester with a discussion about performing under pressure, be it for school, work, or almost any other context. Given the pressure that many of us are feeling now to turn our skill sets towards the global crisis or maybe just to survive final exams, the strategies laid out in this article have probably never been more applicable. The quote:

“Learning to use stress to your advantage is healthy and will give you a competitive edge. Like many career skills, it requires introspection and a commitment to being intentional about the goal.”

2. Next, we heard from Dr. Jodie Guest about the value of reading outside the classroom in The EPI-Curious Society. The quote:

“Learning from our past and talking about our different perspectives is fundamental to doing good work.”

3. At the beginning of February, Dr. Lauren Christiansen-Lindquist helped us to think about APEs differently in her article, Internships: Not just about fulfilling the APE requirement. The quote:

“You may have heard this from me before, but my motivation for pursuing a career in public health was driven by wanting to make a difference. The reason why I love the APE so much is that it affords our students the opportunity to make their mark on public health even before graduation.”

4. In a 3 part series, we heard from alum Roice Fulton (GLEPI, 2014) on careers in global public health with multinational organizations. In Part 1, Roice shared his path from GLEPI student graduating at the height of the 2014 Ebola outbreak in West Africa (more relevant now than ever), to a full-blown career at an unexpected employer. In Part 2, the focus turned toward the nuts and bolts of the global NGO industry and how to navigate your own entry post-graduation. Finally, Part 3 uncovered the role of teamwork and leadership in public health. The quote:

“You may be faced with a call to lead from unexpected places and at unexpected times, especially as we reckon with a pandemic that touches every facet of our work. We’ve got to be ready for the call when it comes.”

5. Epidemiology is not just about the 2×2 tables and the regression coefficients – in our profession, we will also be called to translate science into policy and action. To do that, writes Dr. Lash, we will need to Tell Influential Stories. The quote:

“To be influential, one must change minds. To change minds, those minds must be open to change.”

6. With our schedules packed and mid-semester productivity waning, ADAP Farah Dharamshi introduced the term single-tasking in her article Juggling 101. The quote:

“Our days are filled with a constant barrage of distractions, unexpected challenges and increasing responsibilities. But, the science and experience are clear – by doing less all at once, you will likely be able to accomplish much more.”

7. As Emory, along with nearly every university and employer nationwide, transitioned to remote learning and working, I shared my how-to guide for executing that transition in my article WFH: New Challenges & New Opportunities. The quote:

“This experience is likely to teach you a lot about yourself, your ability to self-manage, your discipline, and your needs as an employee – knowledge that will help you better understand your own strengths and weaknesses going forward.”

8. This Spring, the word ‘epidemiologist’ entered the public domain and left a lot of people outside our profession itching to learn more about what exactly we do. In Dr. Guest’s article The ‘Rockstars’ of 2020, we gained a new way of thinking about our role in society. The quote: 

“In our work, the forgotten past and the unrealized outcomes are our principal indicators of success. Long, healthy lives, not fanfare, signal our victory.”

9. As the need for (and public misunderstanding of) COVID models increased throughout the Spring, Dr. Samuel Jenness provided us with a background on modeling and its application in infectious disease epidemiology in his article Modeling COVID-19. The quote:

“In one sense, models prove their utility in the absence of bad news if they stimulate public action towards prevention, which may have an effect on the shape of the future epidemic curve. In the short-term, public consumers of models may not be able to fully determine the technical quality of that research. But it is important to understand that priorities of newspapers and politicians, and what they find useful in some models, may differ substantially from strong scientific principles.”

10. As the economic impact of COVID became clearer, students wondered what the pandemic meant for their career opportunities. In her article, Job Hunting in the time of COVID, ADAP Noni Bourne gave us some of her insights into the current hiring atmosphere. The quote:

“Human connection is taking on a completely different role in our lives. More than ever, it will be critical to know the person behind the email and to forge relationships that might not have otherwise been so central to success in the workplace.”

11. In Work and Study Efficiency in Difficult Times, Dr. Lash helped us understand that all days are not created equal and, especially today, challenges with motivation and work efficiency are both normal, and acceptable. The quote:

“It might also be helpful to envision what success will look like for you in the long term. We will all one day tell the stories of what happened to us and what we did during the COVID-19 pandemic. You will want to say that you did your part and put your shoulder into it as best you could. Imagine your future self and the story you will want to tell, and then make it so.“

12. In our final PROspective article of the semester, Dr. Christiansen-Lindquist helped trace a path towards identifying APE opportunities during the pandemic in her article APEs: The Best Laid Plans… of 1st-Year Spring. The quote:

“Although your APE might not look like what you had planned, I would encourage you to view this as a speed bump, rather than a roadblock. Our capacity for resiliency is far greater than any of us can comprehend, and these challenging times have the potential to bring out creativity that we didn’t know that we had.”

From all of us on the editorial team, thanks so much for reading PROspective and congratulations for completing another semester! As we transition to our Summer publishing schedule, keep an eye out for more from PROspective going forward.

What was your favorite article this semester? Tell us in the comments!

APEs: The Best Laid Plans… of 1st-Year Spring

MentorRollins

Work and Study Efficiency in Difficult Times

I hope this message finds you and yours well during these difficult times. We have worked hard to keep open channels of communication with students and faculty and, in addition to concerns regarding physical and emotional wellbeing, a recurring theme has been a concern about the efficiency of the time they can allocate to work or study.

There is no single strategy to address this concern; though here are some ideas for how to take it on if you feel your efficiency could be better. It starts with reflection about the source of the self-perceived inefficiency. More than one of the below may be at play, and they may be weighted differently on different days or even over the course of a single day.

If you believe you could be more efficient with the time allocated to work or study, take a moment to think about which of the following may be operating and how to diminish their impact.

Expectations

To start, it’s possible that your expectations of your efficiency are too high. Our schedules have been disrupted, we are grieving the loss or distance of our social networks, and we are all concerned about friends, colleagues or family who are not well and/or experiencing anticipatory grief about the same. It is normal to work less efficiently under these circumstances. Are your expectations of your efficiency calibrated to the reality of the current moment? Is some recalibration necessary? It’s also possible that you need to help your colleagues, instructors, and peers to recalibrate their expectations of you. External pressures that we cannot meet are uniformly demotivating, so do your best to avoid them or resolve them.

Distractions

Second, it’s possible that you are distracted by more than the realities described in the preceding paragraph. When our ability to concentrate is diminished by circumstances, other distractions invade more easily, occupy more time and a higher proportion of mental reserves, and therefore have an ever larger than normal effect on our efficiency. Turn off the email, close the browser, turn off the television and music, keep clear of the kitchen. Duncan’s earlier PROspective article provided some great ideas for creating a productive work-at-home space.

Productivity 101

Third, it’s possible that you could be more productive with the time that you have available. There is a large literature on work productivity, most of which remains relevant even under new circumstances. Make a to-do list for the day that is realistic given the time that you will have available. Delete anything that is not important (aligned with your goals and values). Organize what is left into what is urgent (impending deadlines or helping someone else to keep working) and not urgent (chipping away at larger projects with later deadlines). Take on the urgent and important tasks first, working first on the ones that are least appealing to you. Be sure to save some time each day to work on what is important but not urgent, so that you don’t face unmanageable deadlines later. Work in short bursts without distraction (25 minutes is often recommended), and then reward yourself with a distraction (check email or Twitter or Instagram) for five minutes (no more). You can set a timer to keep the rhythm for you. Be sure, also, to optimize your productivity by eating well, avoiding too much sedentary time, and sleeping well. As advised in Duncan’s earlier PROspective, schedule time to give yourself a break; it’s too easy to sit in front of the work screen all day, even if that time is not productive.

Motivation

Fourth, it’s possible that your motivation has truly waned. Lack of motivation may emanate from a combination of all the above, and is also possibly influenced by feelings of despair and loss of perceived control. To restore some of your missing motivation, start by addressing the first three. Also, find ways to restore a sense of control where you can. We cannot come back to campus for class, but we can organize our closet or write to a high school friend we have been thinking about for a long time. Taking on nonwork items that have been lingering on your personal to-do list will reassert your locus of control, and that will spillover to improve your motivation. Structuring your time will also remind you that you are in control: keeping a daily schedule will help to be sure you have regular sleep, diet, work, and relaxation.

Looking Forward

Feelings of inefficiency during times like these are normal, and some days will be more productive than others. On those days when you aren’t able to tackle as much as you would have hoped, give yourself some grace, and know that you’ll have another chance at it tomorrow. 

It might also be helpful to envision what success will look like for you in the long term. We will all one day tell the stories of what happened to us and what we did during the COVID-19 pandemic. You will want to say that you did your part and put your shoulder into it as best you could. Imagine your future self and the story you will want to tell, and then make it so.

Job Hunting in the time of COVID-19

Living in our new reality is difficult. We all recognize and respect the importance of flattening the curve; but, adjusting to the reality of social distancing is hard. Our daily decision-making process has shrunken to the sizes of our homes and apartments, making going to dinner a question of table or couch.

We need expertly trained epidemiologists tackling today’s public health problems, even while so much is uncertain about today and tomorrow.

Even more difficult is looking towards the future. Yet, we are asking our graduates to do just that. We need expertly trained epidemiologists tackling today’s public health problems, even while so much is uncertain about today and tomorrow.

Still, we know that our rising graduates are looking ahead at how they can leverage their skills during this time of crisis and are eager to put to work their skills at asking and answering important questions. They’re also wondering just how to manage a job search during a global pandemic.

At the end of last month, GLEPI alum Vanessa Da Costa (MPH, 2018) was asked these very questions in an interview with RepoJobs.org – how do you navigate the current job market, what’s different about the hiring process now, and how you should approach networking without leaving the house.

—- 

Let’s think a little more about that last part – networking. Now that we are all doing our part to stay home during the pandemic, human connection is taking on a completely different role in our lives. More than ever, it will be critical to know the person behind the email and to forge relationships that might not have otherwise been so central to success in the workplace. 

What that means is that now is your chance to take advantage of the networking environment. In her interview, Vanessa talked about reaching out to people directly on LinkedIn – simply to learn about their career path. While this might have felt intimidating for some of us in the past, now this sort of interaction is more socially acceptable than ever before. I, myself, am always excited when someone in my network takes the initiative to reach out to me on LinkedIn. To me, this is the first indication that someone would be great employee – resourceful, confident, and motivated.

Vanessa also mentioned the value of attending virtual webinars and events. In particular, I find these places to be great opportunities to identify those people who you might want to reach out to later. An added bonus is that it’s always a little more comfortable to reach out to someone (especially someone with clout) when you can say, “I watched your presentation last week at the conference and I was curious about what you said about ____ .”

“…in the age of remote working and technology, you could be hired to start a position at any time.”

The last part worth mentioning about networking is the element of random chance. Sometimes I like to think about networking more like a chemist. The universe is a container of particles randomly colliding with each other. The laws of chemistry and physics suggest that the randomness or entripy of the universe is constantly increasing, despite our attempts to organize it (at least on our little planet). The more particles you bounce into, the more likely it is that you will encounter the perfect partner particle, and that your electrons will align to form a strong molecular bond. There is a lot about the job search that involves chance, and you’re more likely to create chance opportunities if you maximize the number of encounters you have in the first place. Think of networking like particle collisions, the more collisions that happen (ex. cold calls or emails, introductions, etc), the greater the chance that one of them will result in a real employment opportunity.

—- 

Check out Vanessa’s full interview for more excellent advice about navigating the job market in the days of COVID-19!

Modeling COVID-19

From Dr. Samuel Jenness, Assistant Professor, Department of Epidemiology:

The global pandemic of COVID-19 has raised the profile of mathematical modeling, a core epidemiological approach to investigate the transmission dynamics of infectious diseases. Infectious disease modeling has been featured in routine briefings by the federal COVID task force, including projections of future COVID cases, hospitalizations, and deaths. Models have also been covered in the news, with stories on modeling research that has provided information into the burden of disease in the United States and globally. Along with this coverage has also come interest in and criticism of modeling, including common sources of data inputs and structural assumptions.

In this post, I describe the basics of mathematical modeling, how it has been used to understand COVID-19, and its impact on public health decision making. This summarizes the material I discussed extensively in a recent invited talk on modeling for COVID-19 global pandemic.

What Are Models?

Much of epidemiology (with many exceptions) is focused on the relationship between individual-level exposures (e.g., consumption of certain foods) and individual-level outcomes (e.g., incident cancers). Studying infectious diseases break many of these rules, due to the interest in quantifying not just disease acquisition but also disease transmission. Transmission involves understanding the effects of one’s exposures on the outcomes of other people. This happens because infectious diseases are contagious. Sir Ronald Ross, a British medical doctor and epidemiologist who characterized the transmission patterns of malaria in the early 20^th century, called these “dependent happenings.”

Dependent happenings are driven by an epidemic feedback loop, whereby the individual risk of disease is a function of the current prevalence of disease. As prevalence increases, the probability of exposure to an infected person grows. And prevalence increases with incident infections, and this is driven by individual risk related to exposure.

These dependencies create non-linearities over time, as shown in the right panel above. At the beginning of an infectious disease outbreak, there is an exponential growth curve. This may be characterized based on the doubling time in cumulative case counts. Epidemic potential can also be quantified with R₀, which average number of transmissions resulting an infected individual in a completely susceptible population. The 0 in R₀ refers to the time 0 in an epidemic when this would be the case; colloquially, people also use R₀ to discuss epidemic potential at later time points. Therefore, R₀ might shrink over time as the susceptible population is depleted, or as different behavioral or biological interventions are implemented.

Mathematical models for epidemics take parameters like R₀ as inputs. Models then construct the mechanisms to get from the micro-level (individual-level biology, behavior, and demography) to the macro-level (population disease incidence and prevalence). This construction depends heavily on theory, often supported by multiple fields of empirical science that provides insight into how the mechanisms (gears in the diagram below) fit together individually and together in the system.

Because of the complexity of these systems, and the wide range of mechanisms embedded, models typically synthesize multiple data streams from interdisciplinary scientific fields. Flexibility with data inputs is also important during disease outbreaks, when the availability of large cohort studies or clinical trials to explain the disease etiology or interventions with precision may be limited.

Fortunately, there are several statistical methods for evaluating the consistency of the hypothesized model against nature. Model calibration methods that test what model parameter values (e.g., values of R₀) are more or less consistent with data (e.g., case surveillance of diagnosed cases). Sensitivity analyses quantify how much the final projections of a model (e.g., the effect of an infectious disease intervention) depend on the starting model inputs.

Putting these pieces together, models provide a virtual laboratory to test different hypotheses about the often complex and counterintuitive relationships between inputs and outputs. This virtual laboratory not only allows for estimation of projected future outcomes, but also testing of counterfactual scenarios for which complete data may not be available.

How Are Models Built and Analyzed?

There are many classes of mathematical models used within epidemiology. Three broad categories are: deterministic compartmental models (DCMs), agent-based models (ABMs), and network models. DCMs divide the population into groups defined, at a minimum, by the possible disease states that one could be in over time. ABMs and network models represent and simulate individuals rather than groups, and they provide a number of advantages in representing the contact processes that generate disease exposures. DCMs are the foundation of mathematical epidemiology, and provide a straightforward introduction to how models are built.

Take the example in the figure below of an immunizing disease like influenza or measles, which can be characterized by the disease states of susceptible (compartment S), infected (compartment I), and recovered (compartment R). Persons start out in S at birth, then move to I, and then to R. The flow diagram, kind of like a DAG, defines the types of transition that are hypothesized to be possible (and by an omission of arrows, which are hypothesized not). Movement from S to I corresponds to disease transmission, and the movement from I to R corresponds to recovery. There may be additional exogenous in-flows and out-flows, like those shown in the diagram, that correspond to births and deaths.

The speed at which transmission and recovery occur over time is controlled by model parameters. These flow diagrams are translated into mathematical equations that formally define this model structure and the model parameters. The following set of equations that correspond to this figure. These are differential equations that specify, on the left-hand side, how fast the sizes of the compartments change (the numerators) over time (the denominator). On the right-hand side are the definition of the set of flows in and out of each compartment.

One flow, from the S to I compartment, includes the λ (lambda) parameter that defines the “force of infection.” This is the time-varying rate of disease transmission. It varies over time for the reasons shown in the epidemic feedback loop diagram, shown above, and formalized in the equation below. The rate of disease transmission per unit of time can be defined as the rate of contact per time, c, times the probability that each contact will lead to a transmission event, t, times the probability that any contact is with an infected person. The last term is another way of expressing the disease prevalence; this is the feature of the feedback loop that changes over time as the epidemic plays out.

The overall size of transitions is therefore a function of these model parameters and the total size of the compartments that the parameters apply to. In the case of disease transmission, the parameters apply to people who could become infected, or people in the S compartment. Once all the equations are built, they are programmed in a computer, such as the software tool for modeling that I built called EpiModel. To experiment with a simple DCM model, check out our Shiny app. 

More complex models build out the possible disease states, for example, by adding a latently infected but un-infectious stage (called SEIR models). Or they add another transition, by adding an arrow from R back to S in the case that immunity is temporary (called SIRS models). Or they add extra stratifications, such as age groups, when those strata are relevant to the disease transmission or recovery process. By adding these stratifications, different assumptions about the contact process are then possible; for example, by simulating a higher contact rate for younger persons or concentrating most of the contacts of young people with other young people. These additional model structures should be based on good theory, supported by empirical data.

How Have Models Been Used to Understand COVID-19?

Mathematical models have been used broadly in two ways in the current COVID-19 global pandemic: 1) understanding what has just happened to the world or what will soon happen; 2) figuring what to do about it.

In the first category, several models have estimated the burden of disease (cases, hospitalizations, deaths) against healthcare capacity. The most famous of these models is the “Imperial College” model, led by investigators at that institution, and published online on March 16. This is an agent-based model that first projected the numbers of deaths and hospitalizations of COVID in the U.K. and the U.S. against current critical care capacity under different scenarios. In the “do nothing” scenario, in which there were no changes to behavior, the model projected 2.2 million deaths would occur in the U.S. and over 500,000 in the U.K.

The model also included scenarios of large-scale behavioral change (an example of the second category of use, what to do about it), in which different case isolation and “social distancing” (a new addition to the lexicon) measures were imposed. Under these scenarios, we could potentially “flatten the curve,” which meant reducing the peak incidence of disease relative to the healthcare system capacity. These changes were implemented in the model by changing the model parameters related to the contact rates; in this case, the model structure and the contact rates were stratified by location of contacts (home, workplace, school, community) and age group.

After these models were released, the U.S. federal government substantially changed its recommendations related to social distancing nationally. There was subsequent discussion about how long these distancing measures needed to be implemented, because of the huge social and economic disruption that these changes entailed. One high-stakes policy question was whether these changes could be relaxed by Easter in mid-April or perhaps early Summer.

The Imperial College model suggests that as soon as the social distancing measures are relaxed (in the purple band) there will be a resurgence of new cases. This second wave of infection was driven by the fact that the outbreak would continue in the absence of any clinical therapy to either prevent the acquisition of disease (e.g., a vaccine) or reduce its severity (e.g., a therapeutic treatment). Particularly concerning with these incremental distancing policies would be if the second wave occurred during the winter months later this year, which would coincide with seasonal influenza.

An update to the Imperial College model was released on March 30. This model projected a much lower death toll in the U.K. (around 20,000 cases, compared to over 500,000 in the earlier model). This was interpreted by some news reports as an error in the earlier model. But instead, this revised model incorporated the massive social changes that were implemented in the U.K. and other European countries over the month of March, as shown in the figure below. Adherence to these policies were estimated to have prevented nearly 60,000 deaths during March.

This is just one of many mathematical models for COVID. Several other examples of interest are included in the resource list below. There has been an explosion of modeling research on COVID since the initial outbreak in Wuhan, China in early January. This has been facilitated by the easy sharing of pre-print papers, along with the relatively low threshold in building simple epidemic models. With this explosion of research, much of the world has become interested with modeling research as the model projections are very relevant to daily life, and fill the gap in the news coverage in advance with clinical advances in testing, treatment, and vaccine technologies. Because pre-prints have not been formally vetted in peer review, it can be challenging for non-modelers (including news reporters and public health policymakers) to evaluate the quality of modeling projections. We have seen several cases already where nuanced modeling findings have been misinterpreted or overinterpreted in the news.

As the adage by George Box goes: all models are wrong, but some are useful. This applies to mathematical models for epidemics too, including those for COVID-19. Useful models are informed by good data, and this data collection usually takes time. These data inputs for models may rapidly change as well, as was the case for the updated Imperial college model, so earlier model projections may be outdated. This does not mean that the earlier model was wrong. In one sense, models prove their utility in the absence of bad news if they stimulate public action towards prevention, which may have an effect on the shape of the future epidemic curve. In the short-term, public consumers of models may not be able to fully determine the technical quality of that research. But it is important to understand that priorities of newspapers and politicians, and what they find useful in some models, may differ substantially from strong scientific principles.

Resources

There are many resources for learning more about modeling, including my Spring Semester course at RSPH, EPI 570 (Infectious Disease Dynamics: Theory and Models). We use the textbook, An Introduction to Infectious Disease Modeling, by Emilia Vynnycky & Richard White, that provides an excellent overview of modeling basics. We also have open materials available for our summer workshop, Network Modeling for Epidemics, that focuses specifically on stochastic network models. 

In addition, here is a short list of interesting and well-done COVID modeling studies:

• Original Imperial College model: https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
• Updated Imperial College model: https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-03-30-COVID19-Report-13.pdf
• Model of social distancing in Wuhan: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30073-6/fulltext
• Social distancing model for repeated episodic distancing measures: https://dash.harvard.edu/handle/1/42638988
• Interactive model on the NY Times: https://www.nytimes.com/interactive/2020/03/25/opinion/coronavirus-trump-reopen-america.html
• Age profile of the COVID epidemic: https://dash.harvard.edu/handle/1/42639493
• Model of outbreak on the Diamond Princess cruise ship: https://academic.oup.com/jtm/advance-article/doi/10.1093/jtm/taaa030/5766334

Samuel Jenness, PhD is an Assistant Professor in the Department of Epidemiology at the Rollins School of Public Health at Emory University. He is the Principal Investigator of the EpiModel Research Lab, where the research focuses on developing methods and software tools for modeling infectious diseases. Our primary applications are focused on understanding HIV and STI transmission in the United States and globally, as well as the intersection between infectious disease epidemiology and network science.

The ‘Rockstars’ of 2020

What to do in the time of a pandemic?

So much has happened in the last 5 weeks in the US (longer for other parts of the world, to be sure) and for each of us. We have watched an epidemic unfolding before our eyes. When you are in school studying epidemiology, this is both a movie happening in real life and the core of the very reason you decided to pursue a career in public health. Epidemiologists are making headlines everywhere and your parents, grandparents and friends who were never quite sure what we did (and asked you repeatedly at Thanksgiving dinner) now can talk at length about the work epidemiologists are doing. According to the New York Times on 3/9/20, with regards to COVID-19, epidemiologists are the new rock stars of our current era.

“Epidemiologists, in the main, are assuming it can no longer be contained, and that we should all be responsibly thinking about next steps so that hospitals don’t become overwhelmed. Many of them are worth following on Twitter. Epidemiologists are the new rock stars.”

– Jennifer Senior, Opinion Columnist, New York Times

So let’s talk about what life has been like as an epidemiologist, or one in training, since the end of February. You have had at least one semester considering the ways epidemiologists work, think, and produce data to protect populations or reduce risks. Our thoughts are filled with ideas about how to make the human experience better, either through improving safety, reducing risks, diminishing inequities, or calling out harms. We spent the fall considering the awful side effects of vaping and how epidemiologic data were used to rapidly change policies. That seemed like a once-in-a-lifetime epidemic to happen during your graduate training. Who knew that late winter would give us a much more formidable opponent?

COVID-19, the illness that comes from SARS-CoV-2, was named a pandemic by WHO on 3/11/20. By that time, it had ravaged much of China, having only been first reported on 12/31/19 and named COVID-19 on 2/11/20. Epidemiologists sprang into action taking a wide look at conditions and the myriad of influences that need to be examined. 

One of my favorite parts of epidemiology is that it sits at the intersection of politics, social justice, human behavior, and science.

Conditions are influenced by human behavior, travel, and our climate and these issues needed to be considered immediately. Our singular aim is to improve conditions and keep people safe but epidemiologists found themselves at odds with much of the information being presented by leadership in the US. As the public health world set out prevention measures, they were questioned as being too vast, hard to follow, and invasive to our lifestyle. Epidemiologists were asked to prove they would work, but that is not how this is done when we are talking about a brand new, rapidly spreading pandemic. Here is the interesting thing about enacting changes, particularly prevention measures. You cannot prove that prevention measures work after the fact, precisely because they worked.

Much of public health is about making changes to better human life, but without much attention. It is impossible to determine the number of lives saved from epidemiologic research, yet it is unquestionable that our discipline has saved millions from infectious and non-communicable diseases through the implementation of interventions and preventative programs. In fact, the CDC credits epidemiologists with adding 25 years to the average life expectancy of people living in the US since the early 1950s.¹ This alone, a truly unfathomable accomplishment, is mostly forgotten as evidenced by the 21^st century rise in the anti-vax movement. Yet, in our work, the forgotten past and the unrealized outcomes are our principal indicators of success. Long, healthy lives, not fanfare, signal our victory. 

And yet this week the New York Times has called us rock stars and a new article from the Atlantic on 3/25/20 suggests that this pandemic could elevate public health to the centerpiece of foreign policy while the next generation of kids write school essays about growing up to be epidemiologists. This is not the kind of attention we normally get, but since February, I have answered more texts, phone calls and messages asking for interpretation of data, opinions and travel/health advice than I normally get in a year (or a decade).

Our training to understand and use data to protect our communities has not been needed more in my lifetime…

and you are joining our profession at an incredible moment. It is our responsibility to use our current platform thoughtfully and to own what we do not know, because there is a lot about COVID-19 we are still learning daily. Let’s use our skills wisely, and in a steadfast way that does not bend to the whim of politics, but instead affirms what we know, loudly if needed, and names what we still need to determine as quickly and accurately as possible to protect our world. If we do so with disciplined science and ultimately succeed in preventing a much worse outcome, it is likely the world will scarcely remember our contributions. I do believe, however, we are showing a new generation exactly what it means to make a difference in the world through epidemiology.

WFH: New Challenges & New Opportunities

Let’s take a poll: What is it called when you perform tasks at home that are normally accomplished at your company’s office or the library?

a) Working from home (WFH)

b) Working remotely

c) Teleworking

d) Digital Nomading

e) Pajama Executive

In English, we have a few different ways to say it, but ultimately they all mean the same thing; and represent a practice that many of you are just now trying for the very first time as workplace standards of the last 100 years suddenly, maybe irreplaceably, get upended by a global infectious disease pandemic. 

Working remotely means a lot of different things. While you have probably spent an hour at a coffee shop catching up on email, or taken a conference call from home once or twice when sick, it’s more likely that a permanently remote scenario is new to you. Personally, I’ve been fortunate to travel and work remotely in some capacity for several years, but have been fully remote for the last 11 months – now residing semi-permanently in Medellin, Colombia while continuing multiple jobs from afar.

During this time, I’ve either encountered, fallen victim to, or narrowly avoided many of the classic pitfalls of the Pajama Executive, and today I would like to share some suggestions to help you transition into your new situation. While it may seem disruptive at first, my opinion is that remote work – if designed well – can provide enormous opportunities for professional growth and increased productivity. My hope is that by the end of this article, you, like me, will find more upside in your newfound situation than downside. 

Your Workspace

You’re going to be spending a lot of time here for the foreseeable future. In public health, a common approach to behavior change is to make good habits as easy as possible to accept and maintain. Designing your workspace involves some of the same principles: make your space as comfortable and easy to work in as possible. 

1. Get your technology in order: Identify a dedicated workspace (ideally not in your bedroom, if possible) and arrange your setup with the goal of returning to the same spot every day. The idea is to mimic the conditions at your actual desk in the office. Position your laptop to give you the most ergonomic functionality and appropriate angle and background for video conferences. Test out your call/video conference stability over your wifi network. If your wifi isn’t very stable, do you need to upgrade your internet service? Now is a good time to set up the appointment with your service provider. Strong reliable internet will improve your productivity and, by doing so, ultimately pay for itself. This is why organizations tend to invest a lot in their in-office connectivity. If you are not already required to by your school or employer, consider using a VPN to protect your internet traffic and test any existing connections you might need to access files on the internal servers (Click here for information on Emory’s VPN access). 
2. Routine: How do you normally start your day? Workout, shower, eat a meal (read: drink coffee), get dressed, etc. Repurpose your normal routine to the new context of remote studying or working, and stick to it. Obviously, its reasonable to make more use of your casual wardrobe while working remotely, but for some of us, overdoing it on the casual attire leads to an overly casual disposition – the Pajama Executive might be prone to falling asleep on the job. The best approach, I have found, is to strike a balance and work in clothes that I can feel at least moderately professional in, even if I’m at home. 
3. Food: Working or studying from home can present another insidious challenge – sticking to a healthy diet. At the office or at school, there are socially acceptable times to eat. To break this routine would be difficult, which makes it easy to maintain consistently when you’re in public. However, at home, the (dining room) table is turned – culinary discipline is now 100% in your hands. There are two easy ways to avoid over-snacking, or eating lunch at 10:30am. First, skip the snack foods at the store, and stock up on the healthy stuff. You can’t eat what you don’t buy. Discipline in the store creates discipline in the home. Second, if possible, build your primary workspace somewhere away from the kitchen, and stock it with the essentials you’ll need for the day. We pack our lunch when we go to the office, so why not do the same at home. Ultimately, this strategy works because the less you walk near or through the kitchen, the less likely you are to be tempted. 

Design Your Day

Be deliberate about how you want your days to look. How much time can or should you really dedicate to work versus play. How can you design a situation that will maximize your productivity?

1. Work hours vs. non-work hours: Working remotely can be tricky because your work notifications can go off at any time, even if your work day is over. Most of us now get work email directly on our phones, so this isn’t new. The difference now is that you will have to decide when it is appropriate to respond. Keeping steady, dedicated work hours (communicate them to your superior and your team) can help set the right expectations for you and everyone you work with. Experiment with your “on” allotment and break times, and commit to NOT logging on when you are not scheduled to. This will ultimately help you remain the most efficient when you’re on and the most relaxed when you’re not. The same goes for classwork and studying – make a schedule and stick to it, then maximize your relaxation time when the workday ends. 
2. Daily To-Do list: Distraction starts with not knowing where to start on your work. To-do lists are an excellent solution to this problem. However, one major mistake with to-do lists is forgetting to stop when you’ve finished your list. Sometimes you don’t want to stop the roll you’re on, but it’s better to stick to the list you made a priori because burnout can sneak up on you fast when there is no one else setting the agenda for you. It was the classic American author, Ernest Hemingway who said, “Stop when you’re going good.” He is describing a common existential fear, among authors especially, that if you are on a roll that it won’t last until tomorrow, or that if you don’t take advantage you’ll miss out on some crucial productivity that won’t last until the next day. I personally find this the hardest to do well when I am performing programming tasks. Either way, try not to get sucked into this notion. Hemingway’s approach is based on the idea that if you are in the middle of a productive session towards the end of your day, leaving that inspiration on the table gives you the opportunity to pick it right back up in the morning tomorrow. What inspired your initial productivity will probably inspire subsequent productivity, especially if you return to it with fresh eyes the next day. 
3. Single-tasking: Two weeks ago, ADAP Farah Dharamshi authored an outstanding analysis of multi-tasking and it’s shortfalls. This wisdom is especially relevant for the remote student or employee. Of particular importance, is the idea of single-tasking. Close the tabs on your browser that aren’t immediately necessary for the task at hand, and commit yourself to a single, attainable objective, over a shorter period of time. You will almost certainly notice an improvement in productivity once you start to practice a more focused approach to individual tasks. 

A good employee is…

How would you finish this sentence? 

… is productive.

… is a team player.

… answers emails promptly.

These are all correct answers, all of which are necessary, but probably not by themselves sufficient, to describe a “good” employee. So, let’s try to redefine what this means in the context of remote work. Ultimately, being a good employee doesn’t mean you’re never distracted, or you respond to every email immediately – it means you do your job well and help make the team feel like no one is really remote.

1. Over-communicate: Being remote means we have to compensate a little for the reduction in face-to-face interaction. Be a little more detailed in your emails. Prioritize phone calls over emails, and video conferences over phone calls.
2. Independence: For better or worse, you are probably now going to be asked to perform tasks with less explicit direction than you were used to getting when you worked in the office. This isn’t universally true, because some managers naturally expect more or less independence from their employees. However, this provides a huge opportunity to take on more responsibility for your tasks and remove roadblocks to your success through resourcefulness and determination. This is the kind of initiative every manager dreams of, and will help you become a more productive, low-maintenance employee at home or in an office in the future.
3. Be Flexible: Working or studying at home will inevitably lead to more variability than you may be used to. Expect variability, and roll with it. Your work hours and your co-workers hours may not align perfectly. Everyone is transitioning now, so some people may face challenges that are different than yours. There is a learning curve for everyone, so you might as well embrace it!

WFH: A new normal for the 21st century

It’s hard to say what exactly the workforce of the post-COVID-19 era will look like. Remote work has been popular for the last 15-20 years among a group of backpackers and travelers who coined the term “digital nomad“. This isn’t necessarily what remote work has to look like, but it’s the very first blueprint we have to compare against. Ultimately, as COVID-19 pushes huge swaths of the economy into the home office, it’s very possible that we could be seeing the beginning of a more mainstream revolution in the relationship employees have with their employers and their workplace environment. If this is the case, then now is the time to embrace the new normal and master the WFH lifestyle and workstyle. Either way, this experience is likely to teach you a lot about yourself, your ability to self-manage, your discipline, and your needs as an employee – knowledge that will help you better understand your own strengths and weaknesses going forward. 

Further Reading:

If you are interested in doing a deeper dive into WFH tips and tricks, take a look at some of the articles below:

• Forbes – The art of working remotely
• Vox – Working from anywhere: the good, the bad, and the lovely
• NPR – Tips for making working from home work for you
• Forbes – Building positive habits for full time remote work

Breaking Into – and Surviving In – the Global NGO Sector: Part 3

From alum Roice Fulton (GLEPI, 2014):

On Leadership in Public Health

In the long run democracy will be judged… by the quality of its leaders, a quality that will depend in turn on the quality of their vision. Where there is no vision, we are told, the people perish; but where there is sham vision, they perish even faster.

Irving Babbitt, Democracy and Leadership

As the young leaders of tomorrow, you have the passion and energy and commitment to make a difference. What I’d like to really urge you do is to have a global vision. Go beyond your country; go beyond your national boundaries.

Former UN Secretary General Ban Ki-Moon

Leadership is a tough concept to nail down. It’s a term that, in my experience, seems most readily defined in its absence. Everyone has had the misfortune of witnessing a project or organization falling apart due to lack of leadership.

Though I won’t try to offer a concrete definition of leadership, there are two lessons I’d like to share. One is understanding how leadership roles can suddenly emerge along your career path, and how those experiences can inform a vision for positive change that starts locally, but reaches globally. The second lesson is simply recognizing that you, as young public health professionals preparing for the greatest public health crisis of our time, are each leaders whether you like it or not – because the world as it is today demands it of you.

~~~

While preparing to write these posts, I read through everything on PROspective to see what might help frame my own thoughts on leadership in public health. Every piece of advice given on this blog thus far resonates with my experience – but none so strongly as Lauren Christiansen-Lindquist’s treatise on setbacks (not failures!).

In her article, Dr. Christiansen-Lindquist speaks plainly and effectively to that lingering impostor syndrome that seems to plague our entire generation. What’s more, she offers a strategy for moving forward, and recognizing that moving forward is itself a victory worth celebrating. The qualities she describes reflect qualities I’ve appreciated both in my own fleeting experiences in leadership, and in those whom I consider among the greatest leaders of our generation.

One of Lauren’s suggestions is to share those setbacks. For today’s lesson, then, I’ll share the story of how my biggest setbacks led to some of my most valued leadership experiences.

~~~

In 2007, as part of (what I recognize now as) a futile, years-long effort to atone for a middling undergraduate pre-med performance, I moved to Missouri to volunteer as a member of AmeriCorps St. Louis’ Emergency Response Team. After two weeks of training, I was pulled aside and asked to serve as one of a handful of team leaders, tasked with managing a rotating five-person crew during our deployments to conservation and disaster relief projects.

The year that followed would see us respond to ice storms in Missouri, wildfires in Montana, and tornadoes sweeping across the Midwest – with each new crisis demanding that I balance the welfare both of my team and the communities we raced to support. It was a seminal year that instilled in me a vision of how I could be a force for change in communities beyond my own.

Three years later, I returned home to North Carolina to re-center and re-assess my future. I touched base with friends back home, including attending an alumni reunion at a summer educational program I had attended years prior in high school. After volunteering to build a website for the program’s supporting foundation, it wasn’t long before I found myself installed as its vice president – mere weeks before the program suddenly faced an existential funding crisis.

Working together with about a dozen fellow alumni and supporters aged eighteen to near eighty, we were not only able to scrape together the hundreds of thousands needed to keep the program open – we managed to convince the North Carolina legislature to restore funding in perpetuity. That vision I had in AmeriCorps of being a force for change was suddenly realized at a scale I had scarcely imagined. It remains my most cherished life experience.

Today, I’m almost relieved to hold no overt leadership position. My recent attempt to create a research nonprofit here in Geneva exposed the limits of my leadership ability and credibility at this point in my career. It showed to me that in a high-pressure environment, I’m much more comfortable in a support role, rather than at the head of the table.

And so, I moved on to CEPI, quietly keeping its core business sailing smoothly as the organization navigates the burgeoning coronavirus pandemic. But leadership comes in many forms, and that vision for positive change that I first developed in AmeriCorps and actualized in North Carolina remains and grows – and anchors me firmly to the global community which I now serve. In due time, I expect that I’ll be asked, here or elsewhere, to take on more responsibility – at which point I hope to be ready to deliver that vision to the fullest.

~~~

What I want to convey in sharing this story is that my leadership experiences wouldn’t have even happened were it not for some truly existential-level setbacks. Similarly, you may be faced with a call to lead from unexpected places and at unexpected times, especially as we reckon with a pandemic that touches every facet of our work.

We’ve got to be ready for the call when it comes.

With global leaders now facing a public health crisis partly of their own creation, it’s more important than ever that we, as young professionals, anticipate the leadership duties with which we will inevitably be tasked. We must be champions of reason in our workplaces and in our communities. We must forge strong bonds as teammates and across organizations in overcoming the challenges that face us. We must each craft and test our own vision for change locally, drawing thoughtfully from our lived experience.

And, most importantly, we must execute our vision globally and collectively – and conduct our lives in service to those in greatest need of that vision.

We must do all these things because the world as it is today demands it of us. We must answer that call. We must be leaders.

Roice Fulton, MPH (GLEPI, 2014) is currently an independent consultant for the London- and Oslo-based Coalition for Epidemic Preparedness Innovations (CEPI), where he manages projects in CEPI’s epidemiology portfolio. Roice currently lives and works near Geneva, Switzerland.

Juggling 101

Juggle: to throw several objects up into the air, and then catch and throw them up repeatedly so that one or more stays in the air, usually in order to entertain people¹ 

Sound familiar? 

Just when you think you have it under control, another assignment /project /responsibility gets added to your list. How do you find an APE while keeping up with your readings and assignments, preparing for midterms, fulfilling your REAL responsibilities, navigating your roommate issues, while eating healthy, and trying to get to the gym… Oh – and keeping in touch with your friends across the country, calling your parents… keeping up with the latest episode of…

Or, are you are trying to circumnavigate the pressures of applying for grant funding, preparing course/lecture material, writing articles, dealing with administrative deadlines while balancing the demands of parenting and relationship responsibilities, when your HVAC has to be replaced, and your car transmission is on the fritz…

How are you doing it all?

You multi-task of course. You try to accomplish as much as you can, when you can, all at the same time.

Now, while doing things simultaneously may seem like the height of efficiency, in actuality, it reduces work quality and wastes the precious time you are trying to save, resulting in the need to multitask more to complete your duties/responsibilities. All counterintuitive.

Multitasking forces your brain to switch back and forth very quickly from one task to the next. Interruptions as brief as two to three seconds can be enough to double the number of errors on a task.² Numerous studies confirm that task-switching results in loss of productivity, accuracy, and efficiency, it also reduces the ability of the brain to learn new skills.

While the obvious effects of this are lackluster results in your endeavors, according to Dr. David Meyer from the University of Michigan, the more serious consequences are the adverse effects on your health, because of the constantly elevated stress levels.³ “Multitasking is especially stressful when the tasks are important, as they often are on the job. … The brain responds to impossible demands by pumping out adrenaline and other stress hormones that put a person ‘on edge.'”

Dr. Sandra Chapman from the Center for Brain Health at the University of Texas, has found that “multitasking is a brain drain, that exhausts the mind, zaps cognitive resources, and if left unchecked, condemns us to early mental decline and decreased sharpness.” Numerous studies indicate that chronic multitaskers have increased levels of cortisol, shown to damage the memory region of the brain.⁴

Researchers Ophir, Nass and Wagner at Stanford studying (student) media multitaskers, found that high multitasker students were always drawing from all the information in front of them, and were not able to keep things separate in their minds. “When they’re in situations where [there] are multiple sources of information coming from the external world or emerging out of memory, they’re not able to filter out what’s not relevant to their current goal.”

Doing more things does not determine better results. Doing better things determines better results. Doing one thing to the best of your ability brings about optimal results.

There is time enough for everything, in the course of the day, if you do but one thing at once; but there is not time enough in the year, if you will do two things at a time.

– Phillip Stanhope

Single tasking

Single tasking, as the term implies, is doing one task at a time with as few distractions/interruptions as possible. And yes, it is easier said than done.

Start here:

Do one thing at a time, but do it well.

• The single browser tab habit: limit yourself to having one tab open at any given time to prioritize the task you are trying to complete. And for more motivation, you may be inspired to try a “single-tabbing” challenge like James Hamblin. 
• The evening planning routine: set 10 minutes aside nightly to plan the next day’s tasks –Identify your two-three priorities, and tackle them first.
• Minimize distractions/focus deeply: keep your smartphone in your drawer, turn off your email to focus on one task at a time. This is harder than it seems, so start with 15-minute intervals, and increase to longer time periods of intense focus.
• Get rid of clutter: keep your workspace as minimal as possible
• Use breaks effectively: stand up, drink a glass of cold water, walk around the office perimeter. You will be more effective, if several times during the day you step away from mentally challenging tasks for 3-5 minutes.

For an excellent, more detailed training-plan for single-tasking and focus, take a deep, undistracted dive into this how-to guide from ZenHabits.net. 

Our days are filled with a constant barrage of distractions, unexpected challenges and increasing responsibilities. But, the science and experience are clear – by doing less all at once, you will likely be able to accomplish more much more.