A Doctor’s Perspective – The Dancing Grapevine

On the onset of the pandemic, we reached out to an incredible practising doctor who supplied her insights about COVID-19 and its potential interactions with the dance group. As time has worn on, many people have carried out the accountable factor by following native well being tips.

However, for a lot of, there are nonetheless many questions. Questions I’m under no circumstances certified to reply – however a doctor can. So, listed here are a few of the questions I’ve heard in the previous few months, together with Dr. Hsu’s responses (in addition to my very own commentary, the place indicated).

“I’m studying lots of issues on-line which might be making me query whether or not it’s that large a deal. Are these items appropriate? What’s a great way of constructing certain I’m getting good data?”

Dr. Hsu: That is actually a query about epistemology – the research of information acquisition. The Dancing Grapevine really has a great publish about this (notice from TDG: learn it the entire manner by way of).

In a nutshell: we don’t have sufficient time, alternative, and skill to expertise and check each speculation concerning the world. As a substitute, we depend on folks and establishments we belief to inform us their perspective.

Which means the credibility of the supply and supply medium matter. A number of the supply mediums embody  conventional media, social media, academia, and authorities public well being sources. Relying on the place you’re on this planet, the reliability of every of those sources might differ.

Usually, your native public well being authority is probably going a dependable supply. They’ve a vested curiosity within the well being of your group and are probably run by people with public well being coaching. This implies they dedicate their lives to enhancing inhabitants well being.

Social media is a well-liked option to share data, however is very topic to bias and unverified data. Should you search for data on social media, think about respected individuals who have a background in virology, epidemiology, public well being, or physicians within the area with precise expertise coping with varied elements of COVID-19. These whose epidemiological background is non-existent earlier than March 2020 will not be probably one of the best supply of data. It’s also a good suggestion to analyze any attainable conflicts of curiosity.

Conventional media will also be topic to sensationalism and bias as nicely. Nevertheless, at a sure level, if most conventional media sources, academia (scientific establishments), and respected folks with expertise are all saying there’s a drawback, there’s probably an issue.

TDG Notice: Please do not forget that one seemingly “legit” voice doesn’t make a reality true. The truth is, even a number of dissenting voices don’t make one thing “true”. Within the context of a whole occupation, even 1,000 verified names is a small drop within the bucket of all the occupation as an entire. For instance, in Ontario (one province with a inhabitants of 14.5 million), there are over 40,000 licensed physicians. This doesn’t embody non-physician scientists, nurses, and different well being professionals. The presence of dissenting voice doesn’t make it correct – even with {qualifications}. There’s a motive that on some issues, there’s a bigger scientific consensus.

Additionally, watch out with knowledge. The overwhelming majority of us (together with myself) are woefully unprepared to really perceive its implications. And, it’s very easy for folks we’re counting on to have gotten it mistaken as nicely.

“I don’t know something about scientific analysis or knowledge, however I see lots of graphs that say this isn’t an enormous deal or give conflicting reviews about knowledge. What are some fundamentals that I can use to assist me perceive what’s happening and establish good knowledge or analysis research?”

TDG: Right here’s an excellent podcast on the impression of trusting sources

Sure, COVID is an enormous deal. Nations all around the globe don’t drastically change behaviours for no motive. Additional, nations will not be organized sufficient to create a large world conspiracy. Give it some thought: they’ll’t even agree on the little issues.

If you would like a e book that will help you perceive issues extra deeply, “The Guidelines of Contagion” by Adam Kucharski, PhD mathematician at London Faculty of Tropical Medication and Hygiene, who constructed his profession on infectious illness epidemiology, is great and straightforward to learn.

I’ll attempt to clarify why it is a large deal and the fundamentals you should utilize to know what’s going on, however be forewarned: it’s lots of arithmetic.

TLDR: Refrigerated vans exterior hospitals to choose up lifeless our bodies as a result of the morgues have exceeded capability seem to be a fairly large deal.

Historical past of Pandemics

Pandemics have impacted and altered human society all through human historical past. Newer ones documented, together with the medieval Black Dying, smallpox in North America, and the Spanish Flu of 1918-19. In these circumstances, there’s a novel infectious supply that nobody within the inhabitants has immunity towards. This implies everyone seems to be prone to an infection. People then (attempt to) regulate their behaviours to scale back transmission in response. That is helpful for collective survival. Efforts are nicely documented, even when some approaches have been restricted by the data of the time.

Now, we enter a query of arithmetic and scale. If you take a worldwide inhabitants of seven billion when there’s virtually common susceptibility(or perhaps a theoretical nation/metropolis inhabitants of 10 million), the potential for hurt is critical.

The obvious impacts of the virus are:

  • Mortality (deaths)
  • Morbidity (long run well being penalties)
  • Lengthy-term psychological penalties for critically sick sufferers and their households
  • Healthcare system capability
  • Psychological and bodily well being of healthcare staff, and their family members.

The long-term impression of lots of these items is but to disclose itself.

The financial and psychological impression of measures taken to scale back unfold are additionally vital. Nevertheless, it’s value noting that the comparability group for these impacts must be an uncontrolled pandemic – not life in 2019. Whereas tempting to check our present state to what life was, it isn’t correct.

No matter how “small” the mortality price is perhaps, while you multiply that by sufficient contaminated folks, it turns into vital. Even .5% of 10 million is 50,000 further deaths that will not have occurred. It’s also now clear that COVID disproportionately impacts susceptible and historically deprived teams together with:

  • Seniors
  • Folks with disabilities
  • Folks with continual well being situations (a big portion of the inhabitants), and,
  • Folks of color, who disproportionately occupy important, lower-income jobs which might be troublesome to do from residence (in Canada, not less than).

Which means there’s additionally a element of fairness to be thought-about within the response as nicely. It’s also value noting {that a} not-insignificant variety of younger folks and folks with no pre-existing situations can and have died, turn out to be critically sick and/or expertise long-term well being impacts from the virus. This virus goes past “solely impacting previous and sick folks.”

Studying Analysis Papers

Should you’re going to attempt to learn medical analysis papers and don’t have the coaching to take action, perceive that you simply most likely gained’t perceive the nuances and implicit data. That’s okay.

I don’t attempt to learn engineering analysis papers as a result of I’ve no coaching in that area and don’t perceive the paper’s assumptions nor do I’ve background data to tell my understanding. I can attempt to learn papers in laboratory/molecular medication however with nice problem as a result of, once more, I don’t have vital coaching or expertise in it.

I really feel pretty assured in my capacity to parse out the knowledge in scientific trial analysis papers, together with understanding their strengths and limitations, however that took a few years of finding out in a related area with further particular analysis methodology training.

It’s vital for us as people to acknowledge the bounds of our data. We could be humble and curious and attempt to study extra, but it surely’s vital to not assume the skilled function within the course of. With that in thoughts, listed here are some fundamentals that will help you perceive a few of the language:

Generally referenced language:

  • IFR = an infection fatality price = variety of deaths divided by variety of contaminated people in a inhabitants
  • CFR = case fatality price = variety of deaths divided by variety of recognized contaminated people in a inhabitants
  • Assault price = quantity of people that find yourself contaminated in a bunch of vulnerable folks (That is excessive for SARS-CoV2)
  • R0 (pronounced-naught) = the transmissibility of the virus, on common, assuming no modifications are in place and in a vulnerable inhabitants.
  • Rt = present transmission price based mostly on real-time knowledge. This quantity modifications based mostly on insurance policies and our collective motion.
  • Ok = dispersion parameter

Testing Capability

Testing capability in a given location can impression the variety of recognized people, not the precise price of contaminated (till we use the variety of recognized infections to change our behaviour). For instance, if you’re pregnant, it’s possible you’ll not have a constructive being pregnant check since you didn’t pee on a stick, however you’re nonetheless pregnant. The identical goes for COVID: these contaminated that haven’t been examined aren’t counted.

Additional, exams do have false damaging charges. PCR, the check after they put a stick up your nostril/throat to search out viral genetic materials, could be falsely damaging pretty often – however is never falsely constructive. Usually, false-positives for the PCR check will not be a difficulty. 

Understanding Assault Fee

COVID is a novel pathogen. We now have been in a position to research it in cruise ship, weddings, jail, and different outbreaks the place giant teams of individuals have been in shut proximity for lengthy durations of time. In these conditions, an assault price of 80-90% has been noticed. Which means COVID has a excessive assault price, and opposite to the “T-cell immunity” arguments: most individuals are not already immune.

Understanding Ro and Rt

Ro is our common understanding of how transmissible a virus is. SARS-CoV2 has a suspected Ro of 2-3 based mostly on transmission noticed in early Spring. Which means each contaminated particular person, on common, spreads to 2-3 folks, and every of these, unfold to 2-3 extra. This causes exponential development.

Rt is concerning the present transmission price. This differs barely from Ro because it has to do with how issues are presently progressing in a particular space.

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

When R = 1, every case infects one different particular person and the epidemic will proceed to develop on the present an infection, so if R hits 1 at 100 circumstances per day, it would proceed at 100 circumstances per day; if it hits 1 at 1000 circumstances per day, the following day will nonetheless be extra 1000 circumstances.

When R < 1, every case infects lower than one different particular person on common and the epidemic finally dies out

Do not forget that the epidemic is rising exponentially each time R > 1. This implies we’ve to work towards our personal instinct. Our brains are wired to know linear (fixed) development a lot better than exponential.

Think about you’re crossing the road and a automotive is coming in the direction of you at fixed velocity, versus if that driver presses the gasoline and they’re approaching you with acceleration. Responding as if the automotive is coming at you with linear fixed velocity when it’s accelerating in the direction of you’ll improve your threat of hurt considerably.

We’re the pedestrian, exponential COVID development with R >1 is the accelerating automotive.

Virus Variations

You’ll have heard concerning the new dominant COVID variant sequenced within the UK: B.1.1.7. It is very important notice that viruses mutate on a regular basis. Every time they replicate, there’s a probability of a “mutation.” Normally, these mutations don’t result in any vital modifications that impression folks.

General, SARS-CoV2 is a reasonably large virus that stayed remarkably secure and constant for a lot of months. Sadly, with widespread transmission and extra viral replication, there are a few early 2021 variants which might be regarding. We presently have extra details about B.1.1.7.

Early estimates recommend it may very well be as much as 50% extra transmissible. Mathematically, a better transmissibility is definitely extra regarding for inhabitants mortality than a 50% larger fatality price.

This has to do with the R. Credit score to Adam Kucharski for the next illustrative instance:

“If the present Rt=1.1, and we estimate an infection fatality threat as 0.8%, with era time of 6 days, and 10k folks presently actively contaminated (believable for a lot of European cities just lately), we’d anticipate 10000 x 1.1^5 x 0.8% = 129 eventual new fatalities after a month of unfold.”

What occurs if fatality threat will increase by 50%? By above, we’d anticipate 10000 x 1.1^5 x (0.8% x 1.5) = 193 new fatalities. Now suppose transmissibility will increase by 50%. By above, we’d anticipate 10000 x (1.1 x 1.5)^5 x 0.8% = 978 eventual new fatalities after a month of unfold.

This improve of transmissibility issues extremely at the moment. Vaccines are on the horizon. Behaviours that have been maybe an “acceptable threat” beforehand, is probably not now. We’re drained, and folks turn out to be complacent when drained. Please attempt to view new data with recent eyes, and adapt behaviour accordingly.

From TDG: There’s a cell recreation referred to as Plague Inc. For a non-sciencey manner of understanding why a extra infectious virus is extra regarding than a extremely deadly one, attempt taking part in with mutations and evolutions within the recreation. You’ll shortly discover out viruses can principally kill themselves off if the fatality price is simply too excessive in distinction to its unfold price. Clearly, larger charges of demise are horrible and scary – however don’t underestimate the quantity of harm a less-lethal virus can do if it isn’t stopped from spreading. 

Understanding Ok

Ok = dispersion parameter. That is used to account for the truth that most COVID circumstances are attributable to a small variety of contaminated people, and most people who find themselves contaminated don’t infect anybody else, or infect solely a small variety of people.

Knowledge helps that SARS-CoV2 is pushed considerably by “superspreading” occasions. Japan has had success maintaining their society largely open by particularly concentrating on superspreading occasions, and the environments which make it extra probably.

That is related to social dancing as a result of social dances ave a excessive potential to be superspreading occasions. They contain folks in shut bodily contact, respiratory closely in the identical air, for extended durations of time.

“Why do scientists, docs, and public well being professionals appear to disagree on issues or change their method once in a while? Doesn’t this imply that they don’t know what we’re doing and we must be skeptical?”

The Novel Coronavirus is new, because the identify suggests. When it started in late 2019, nobody knew something about it. We’re constructing the airplane as we fly it.

Science as a area is about acquisition of information by way of testing of various hypotheses. We draw impartial conclusions based mostly on all accessible proof, and alter our conclusions when new data suggests it’s prudent. It has labored like this for hundreds of years. The pandemic has accelerated this course of, and data about SARS-CoV2 is being acquired at unbelievable velocity. I think about it’s jarring for folks with no science background to view this taking place in real-time.

Disagreements in science are wholesome and part of the method. Ultimately, we oscillate in the direction of an settlement. Even then, there will likely be some variability inside the consensus. That is all part of the scientific course of.

Simply bear in mind: altering your conclusion within the face of latest proof is science. Ranging from a conclusion and on the lookout for proof that helps it’s ideology.

“What’s the distinction between a public well being official, a physician, and a common scientist? I see some docs and scientists saying it’s not an enormous deal.”

Public well being is the research of well being for a inhabitants, with focuses on prevention and well being promotion. Individuals who work in public well being could also be medical docs or come from a special background, however they’ve in depth coaching in finding out well being throughout a big group of individuals.

A medical physician research illnesses, diagnoses, remedies, and applies their data to deal with people. From a scholastic perspective, it’s somebody who has an MD diploma.

Notice from TDG: An MD doesn’t imply somebody is licensed to supply medical providers – that is normally carried out by way of a School of Physicians or different group. Relying the place you’re from, the {qualifications} and training required to be a licensed, practising doctor might differ. For instance, some locations license naturopaths or chiropractors the identical manner they license MDs. Some have a separate course of for these teams. Some don’t acknowledge these teams as a practising doctor in any respect, and will not even regulate these fields. 

A common scientist could be from many fields. They collect knowledge from completely different sources by way of completely different strategies and attempt to synthesize the knowledge, check hypotheses, and draw impartial conclusions.

Regardless of the larger scientific consensus that local weather change is an enormous deal and the problem of our lifetimes, there are nonetheless scientists which deny its existence. That is just like how most docs and scientists agree that the COVID pandemic is an issue.

If 97% (theoretical proportion) of scientists agree there’s a drawback, it’s unusual to deal with the three%. There are various approaches on administration, however the place to begin of settlement is that there’s a drawback.

Notice from TDG: Ontario alone has over 30,000 physicians licensed to practise medication. Which means 3% of that quantity can be 900. If we apply this to even bigger numbers (for instance, all healthcare suppliers, all physicians in North America, all scientists) it turns into clear that even having 5,000 dissenting voices remains to be a reasonably small quantity with regards to trusting the phrase of some over the numerous. This is perhaps a great factor to consider the following time somebody claims that “hundreds” of execs disagree, and that this in some way means there’s a giant proportion of dissent.

“Some folks say that issues aren’t that dangerous. You’re a physician. What have you ever seen? How has it modified your work?”

COVID pandemic has modified my work immensely, from small mundane methods to large ones.

A each day change is that I’ve to put on a masks for all the time I’m at work. Consuming and consuming is troublesome as we have to discover a non-public place to take away our masks, which implies I’m going by way of each day involuntary intermittent fasting (I actually appreciated snacking within the “earlier than” occasions). I additionally see a big improve in my sufferers’ now-profound loneliness in hospitals whereas recovering from sickness, as they don’t seem to be allowed guests nor to depart the grounds.

I’ve seen the morbidity attributable to COVID. I’ve seen strokes inflicting paralysis and protracted neurological deficits inflicting an incapability to stroll. I’ve seen persistent problem respiratory, the place common actions like strolling upstairs is difficult.

I’ve additionally seen psychological trauma from intensive care unit stays. For instance, think about being partially sedated, a tube in your throat that you simply can not pull out since you are paralyzed, and never with the ability to converse or ask for assist. Think about being solely partially awake, confused, with shadowy figures in robes towering over you.

I don’t work in intensive care, however I imagine the tears of my colleagues after they discuss holding up video telephones to let sufferers see their family members, presumably for the final time, previous to intubating them (once we put a tube down your throat and hyperlink as much as machine that will help you breathe).

I imagine the fear in having your complete intensive care unit stuffed with COVID sufferers, and having to decide on who will get remedy, and realizing that many different individuals who want remedy for different causes is probably not getting the care they want as we grapple with this disaster.

“Are temperature checks enough to verify folks don’t have COVID-19?”

Brief reply: No.

Lengthy reply: No, as a result of there could be so many false negatives. For instance:

  • How are you taking the temperature verify? Brow thermometers are unreliable.
  • How are you defining a “fever”? Many COVID circumstances have “low-grade” fevers, or none in any respect. Many circumstances have fever solely at some a part of their illness course, however not all through.

We can not see into the longer term. Persons are most infectious proper earlier than they get signs. You don’t have any manner of realizing if the particular person in entrance of you is contaminated if they’re asymptomatic or haven’t any fever.

“I went to a health club that doesn’t require masks and I’m advantageous. So, why can’t we maintain dance socials?”

Gyms nonetheless trigger outbreaks. They’re a higher-risk setting as it’s enclosed with folks respiratory closely. Even with this in thoughts, you’re most likely not placing your face subsequent to a different particular person’s face on the health club; you’re in social dancing.

We additionally have to remember that inhabitants threat is completely different from particular person outcomes. Indoor gyms are a higher-risk setting and social dancing is a high-risk exercise. The truth that some people gained’t get contaminated doesn’t negate the danger potential.

“What issues ought to I see in my space earlier than it’s secure to carry an area social or class?”

Once more, “secure” doesn’t exist, solely safer. Ideally:

  • a Rt a lot lower than 1
  • < 1 lively COVID case per 100,000 folks in a inhabitants
  • Take a look at % positivity is < 1% (variety of constructive exams in a day, divided by variety of exams carried out that day) and your space has enough illness surveillance with sturdy testing, contact tracing, and case isolation mechanisms, with out vital outbreaks or strained hospital assets. That is vital as a result of a excessive constructive % signifies a excessive probability that there are numerous extra circumstances int he group which might be being missed.

Even then, folks transfer round and circumstances can change shortly. In case you are in New Zealand or Taiwan in late 2020, you’ll be able to probably do no matter you’d like. Everybody in North America/Europe with vital group transmission, even when the place you’re meets these thresholds, probably nonetheless must have courses with some behavioural modifications.

Social dancing with accomplice switching would considerably improve threat of transmission as it’s growing the variety of contacts. Subsequently, except you’re in a spot that has principally eradicated the virus, it’s not a good suggestion.

“My space is permitting courses. What precautions can I take to verify they’re safer?”

Outdoor is way safer than indoors. You also needs to put on  a masks to scale back the stuff popping out of your nostril/mouth from getting breathed in by different folks. Lastly, you must scale back the variety of folks you dance with, acknowledging that you don’t have any management over who they dance with or who they see regularly.

“If I take advantage of followers and open home windows, is it secure to host my social/class inside?”

“Are indoor courses and socials secure if everybody wears a masks, checks temperature, and doesn’t swap companions?”

“Are in-person non-public courses secure?”

“Are outside socials secure?”

Danger is cumulative and relative. There is no such thing as a secure, solely safer. Whether or not it’s an appropriate diploma of “secure” to have a category or social relies on the transmissions in your space, your native public well being and hospital’s capacity to deal with the present infections, and the person threat tolerance of your attendees. See the colour-coded determine beneath.

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

Out of doors is certainly safer than indoors. Opening home windows is a good suggestion to enhance air flow; it’s unknown whether or not that may make a major sufficient distinction to the litres of recent air per minute introduced into the room. This relies on the climate, measurement of the window, measurement of the room, and variety of folks respiratory within the room.

The good thing about followers unclear. Whereas it could improve circulation of out of doors air, it could additionally improve circulation of virus-ridden air.

If everybody wears a masks and maintains just one dance accomplice, that would scale back the danger. Likewise, a personal class with one accomplice with whom you will have shut contact and a socially-distanced teacher can also be much less dangerous. However, if an teacher is having in-person non-public courses with a number of folks, then their threat of an infection will increase, they usually threat infecting a number of folks.

Temperature and symptom screening must be mandated all over the place. It’s a naked minimal to ask symptomatic people to not partake, acknowledging that it’s in itself, not enough to ensure security, on account of asymptomatic/pre-symptomatic unfold.

“I actually need to apply dancing. How can I apply safely if I don’t stay with a accomplice?”

Now is a superb time to work on solo dancing. It’s going to enhance your stability and method, and enable you to tune in to your personal physique. Should you actually need to accomplice dance, see if you could find somebody in your neighborhood who consents to being your (monogamous) dance accomplice whereas we’re within the pandemic. After all, you’ll be able to change this accomplice, however think about a strict 2-week quarantine previous to partaking with a brand new particular person. Testing has a excessive price of false negatives and isn’t a alternative for bodily distancing and quarantine.

When do you assume occasions will have the ability to occur?

I’m not a fortune-teller. Speculatively and optimistically, vaccinations will likely be given all through 2021, and perhaps later a part of 2021 can have some smaller occasions in locations the place large vaccination have occurred. Huge dance occasions like we used to see with folks touring internationally and face-rolling on a whole lot of random strangers over a weekend will most likely be relegated to 2022 or later.

Right here’s a hypothetical dance situation to elucidate these timelines:

  • Dance congress with 1000 contributors.
  • Assault price of 85% as dance congress is as high-risk superspreading as we are able to get
  • 850 contaminated and have to miss work and isolate for two weeks, maybe requiring their complete family to quarantine as nicely.
  • If 10% have vital a morbidity that’s 85 individuals who might not have the ability to work or stay healthily for weeks to months, or longer. A few of them might require hospitalization.
  • Low-end of common IFR estimate at 0.5%, means 4 deaths.

That is assuming the 850 folks in some way don’t infect others, which is unlikely.

For a real-life situation: a 55-person wedding ceremony in Maine led to 177 circumstances, 7 hospitalizations and seven deaths. The individuals who died weren’t on the wedding ceremony; they caught it from individuals who have been.

“The shortage of dance and group has actually impacted my psychological well being. Do you will have any solutions?”

I additionally work in psychological well being and substance use. I empathize with the psychological well being challenges introduced on by the pandemic and its required restrictions. I feel we’ve all been impacted by the pandemic in some ways.

Psychological well being has two parts – exterior elements (that are largely not in our management), and inside assets (that are in our management). These parts will not be fastened. We will construct from the fundamentals; for instance, listed here are some well-supported strategies to keep up well-being:

  • Consuming a nutritious diet commonly, together with minimally processed fruit and veggies
  • Sleeping nicely, for nevertheless many hours your physique wants, on the identical schedule. Lookup “sleep hygiene habits” if you happen to’re new to the time period; this may help.
  • Common train – indoor, outside; no matter you’ll be able to really handle to get the vitality to do this is secure within the present local weather.
  • Not utilizing substances as a coping technique. Specifically, look ahead to the glorification of alcohol as a coping mechanism and self-monitor your consumption.

Different methods of enhancing psychological well being embody reaching out to communities nearly and sustaining social connections regardless of not with the ability to see folks in particular person.

Mindfulness is a apply that I encourage everybody to take a look at. It helps us carry our consciousness to the current second and work on accepting no matter we’re feeling/experiencing, with out judgment. There’s a deal with self-compassion, and empathy for these round us and for the world. That is one other manner of gaining inside assets.

Notice from TDG: In case you are in disaster, please don’t delay getting assist. Listed here are some assets:

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

We live in a time of uncertainty. That alone is anxiety-provoking. People wish to plan and dream about their future. It’s regular to have some inside resistance to the truth that we can not try this proper now. Nevertheless, we should settle for this to maneuver ahead.

A manner I take a look at it’s that ache + resistance = struggling. Ache is inevitable in life, struggling is elective. Once we scale back our resistance to accepting issues as they’re, we are able to higher see what is definitely in our management. We will nonetheless attempt to be thankful for what we do have. I like to recommend a each day gratitude apply as one other methodology of gaining inside assets. Now greater than ever, we must be considerate, compassionate, form, and centered on the larger good.

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