Covid Conversations I: Collateral Damage
Snippets of an ongoing conversation about the benefits and risks of Covid mitigation strategies
[Headnote: The following is an informal, open-ended, ongoing conversation-in-writing about Covid. It is meant to represent the kinds of conversations we’ve been having with people we know, including friends and neighbours and especially with each other, the kinds of conversations we suspect thinking people all over the country are having.
Needless to say, we aren’t epidemiologists—and neither, to our knowledge, are any of our readers. We think, however, that the conversations we have about Covid—the public ones represented by public health guidance, peer review of medical studies, media (and social media) reportage and opinion; as well as the private conversations citizens have with one another and with their doctors—are how we make meaning of the pandemic. It is at this level that people—individuals as well as communities—make decisions about how to deal with and understand Covid, and infectious diseases in the aftermath of the pandemic.
It is now clear that there is no singular or straightforward way to think about the pandemic. The origins of Covid, the nature of the virus itself, the range of preventative measures and treatments, the scope of public health guidance, people’s private opinions about Covid and their willingness to go along with public health measures imposed on them—all these things have been subject to considerable change and often controversy over the past three years. There is, contrary to some claims, no simple set of protocols ‘everyone’ should have followed: the very wide range of international responses to Covid has amounted to a very massive natural experiment in which no approach has succeeded in vanquishing a virus that has done what viruses always try to do, which is find ways to make itself endemic.
Given that (it now seems) Covid was always, eventually, going to become endemic—that the best outcome was always going to be reaching a kind of epidemiological détente with the virus—it seems time for our conversations about Covid to shift. One issue we have found ourselves returning to, over and over, especially recently, is: What has been the collateral damage of our Covid mitigation strategies? How can we do a better job of weighing the benefits—and risks—of any given set of public health measures? What can we learn from our successes, as well as our mistakes?
Risk-benefit analysis is a core concept in science, and perhaps especially so in medical and drug research. It is also a vital element in evaluating public decisions. At the same time, humans and human societies are famously bad at weighing risks (especially relative risks), not only when there is a sense of urgency but also when there is not. A lot of this has to do with our perceptions of risk (and relative risk), which tend to be highly variable as well as resistant to evidence. Three years into the Covid era, we think it’s time for more coherent, and balanced, risk/benefit analysis of Covid mitigation strategies deployed during the pandemic, and this is the focus of our current conversation.]
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[Amy] As I write this, Emergency Rooms and Intensive Care Units all over Ontario are overwhelmed with seriously sick patients, almost all of them, at least according to news reports, very young or very old.
This might seem like a grim repeat of the last three years—except that these people aren’t, for the most part, sick with Covid.
Rather, they are sick with Respiratory Syncytial Virus (RSV), a virus ordinarily so infectious that the US Centres for Disease Control reports that nearly all children contract it as infants; Health Canada echoes this information and adds that reinfection is so common that kids can have up to five or six RSV infections a year. Adults are susceptible, too: the National Institute for Allergy and Infectious Diseases (NIH) reports that an estimated 64 million people experience RSV globally each year (of whom about 160,000, almost all very young, very old or otherwise vulnerable, die).
The problem with RSV is that, even before the pandemic, it was a leading cause of infant hospitalizations with, in Canada, an estimated pediatric hospitalization rate of 130 per 100,000. A 2017 Canadian Respiratory Journal article reported that, in Alberta, 13.4% of infants hospitalized with RSV ended up in the ICU, with ICU stays lasting an average of 6.5 days.
RSV is only one of several viruses disproportionately affecting the very young. A 2006 article in the Pediatric Infectious Diseases Journal reported that influenza (hospitalization rate of 18 per 100,000—or an alarming 200 per 100,000 among infants aged 6-11 months), parainfluenza /PIV (160 per 100,000) and other influenza-like viruses (70 per 100,000) represent a serious disease burden among young children.
As any parent will confirm, kids seem to spend the first years of daycare and primary school coming home repeatedly with a variety of viruses they’ve caught from other children. Late-night visits to pediatric urgent care clinics because a child has suddenly spiked a fever, is vomiting uncontrollably, or experiencing febrile seizures are basically parental rites of passage. The treatment is almost always prophylactic—over-the-counter medication to reduce fever, extra fluids, warm blankets, and coffee or the harder stuff for exhausted parents—unless a young child goes into respiratory distress. Even then, supplementary oxygen and IV fluids are the main line of defense, because there are no vaccines and few antivirals for most of these bugs. By middle school the viral storm clouds have mainly cleared, with older kids getting the same 4-6 colds most adults get each year and shrugging them off in a week or so, but in early childhood it’s a barf-and-snotrag shitshow.
Imagine a triple cohort of little kids coming down with these viruses all at once, and you have the reality overwhelming hospitals right now—the first ‘normal’ (schools, daycares, sports programs, etc. open for ordinary, non-distanced, in-person learning and playing) fall since 2019.
Is it possible our Covid mitigations strategies worked too well?
Early in the pandemic, the City of Toronto literally locked up playgrounds so children, even then widely (and erroneously) identified as vectors of the disease, would neither contract nor spread Covid. Hallowe’en was actually cancelled in October 2020 in Toronto, Ottawa, and other regions deemed Covid hotspots. And, of course, despite wide acknowledgement that schools should be the last to close and the first to open, Ontario schools were closed to in-person learning for months at a time between March 2020 and early 2022, reportedly the longest closures in any jurisdiction in North America—apparently to no benefit whatsoever.
At first these measures met with wide public support. On social media, shrill invective was leveled at parents who allowed their children outside at all. At one point an image made the rounds on my social media feed, criminalizing in escalating order activities like buying toilet paper (this was likened to manslaughter) or encountering friends outdoors (rated as a form of mass murder)—this was around the time a subsequently-debunked visual went around claiming that joggers and cyclists exhaled long trails of Covid aerosols, potentially infecting everybody in their wake. As the holiday season approached, parents who bought presents for their kids were called murderers. Predictions were made that opening classrooms to in-person learning would cause massive superspreader events, although school openings, when they were finally and intermittently permitted, appear to have been connected only to modest increases in caseloads, almost all mild or asymptomatic.
Not long into the pandemic, concern began to be raised about the collateral damage prolonged school closures would cause kids. These costs included learning loss, deficits in socialization, and lack of access to mental health supports and even food programs. In June 2021 the since-disbanded Ontario Science Table identified learning loss as a major consequence of Covid-related school shutdowns, and by the fall of 2021 educators and education advocates were loudly sounding the alarm. For its part, early in 2022 the provincial government announced funding to make up for some of these losses. By the fall of 2022, the massive scale of learning loss had become undeniable, and by this month, evidence of the accumulated costs to children—academically, socially, medically—had become overwhelming. Recovery is going to take years—and many children will likely never catch up.
As for the perfect storm of RSV hitting a large cohort of kids who’ve never previously been exposed to it, alongside the robust return of cold and flu season more generally—this was a danger infectious disease experts warned us about over a year ago. It was inevitable, following years of isolation, that common infectious childhood diseases would rebound; inevitable, too, that sick little kids would overwhelm emergency departments already stretched beyond their limits not only by pandemic-related illnesses but by years of budget cuts.
How could we have handled the pandemic better, particularly with respect to the educational and medical well-being of children? This vital question is now being asked by researchers in a variety of fields, but I think it’s something we as citizens should be weighing as well. Was it really responsible to shrill “Close. All. Schools. Now.” for nearly two years despite the documented costs to children’s learning and socialization? Was literally locking up playgrounds and threatening people with fines for sitting on park benches a reasonable response even to a then-mysterious public health threat? Did cancelling Hallowe’en in 2020 (and discouraging kids from trick-or-treating in 2021) do more harm than good? Should schools have continued to cancel recess, field trips, contact sports and graduations even after nearly every eligible adult in the country had been vaccinated?
I don’t have straightforward answers to any of these questions. It’s actually my view that absolutism—oversimplified, knee-jerk insistences that have disregarded basic principles of risk management and evidence weighing, not to mention basic practices of good public health communication (and for this I blame both Covid-is-everything shouters as well as Covid deniers)—have actually brought us into this debacle in the first place. I think, especially, that nuance was disastrously lacking in decisions around repeated school closures and the prolonged isolation of children from one another and from society more generally, and that this lack of nuance has cost our kids very greatly.
Despite calls from some quarters to reinstate mask mandates, there is likely insufficient justification to do so—including the reportedly limited effectiveness of masks in preventing the spread of RSV, and because annual flu shots are the best and most longstanding defense against seasonal influenza. Covid continues to circulate at moderate levels, as it will likely do for the foreseeable future now that it has become endemic, but seems now to be part of the epidemiological landscape, somewhere between the common cold and seasonal influenza. This doesn’t make Covid negligible—Covid death rates remain stubbornly high among the elderly—but it may make it comparable to influenza, which is not negligible either (in Canada, influenza results in an average of 12,200 hospitalizations and 3500 deaths in a typical year ) but at least has somewhat predictable ebbs and flows.
Advice to wear a mask when experiencing viral symptoms (or, better yet, to stay home when sick when it’s possible to do so) is reasonable, reasonably if imperfectly effective and, for the most part, practicable. A mask mandate is likely to result in blowback, would be difficult to enforce, and may undermine other public health guidance, particularly with respect to the importance of keeping vaccinations up to date. It is also worth noting that, after the repeated, prolonged and ultimately destructive shuttering of schools, gyms, community centres, libraries and malls in Ontario during the pandemic, the notion that a renewed mask mandate might be “temporary” has little public credibility. A mask mandate will also do nothing to solve the chronic problem of overwhelmed hospital emergency rooms, and do little to mitigate the acute emergency of a triple cohort of little kids getting sick all at once—rather, it will likely mean a new and perhaps even higher peak of pediatric admissions next fall, and the fall after that, and the fall after that.
Maybe—if we really do mean to think of the children—we can do better than that.
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[Peter] In hindsight there certainly seems to have been a counter-productive amount of hysteria in both private responses and public Covid policies. Some medical professionals contributed. Sometimes it was cooler political heads that fortunately prevailed — as when Dougie refused to go along with some of the essentially 0-Covid draconics the ‘Science Table’ kept advocating at that time.
Was shutting down schools hysterically wrong? Sure it was — in hindsight. It was both inordinate and unwarranted. We have robbed the future of an entire generation and shattered the possibilities of who our children might otherwise have become and been. We do realize that now belatedly, in hindsight. Hence, for instance, Dougie’s reflexive, horrified use of the Notwithstanding Clause to protect children from CUPE’s striking threats. Now that we realize how inordinate and unwarranted the harm done, it’s nigh unthinkable to persist harming our children yet again.
Some hysteria should be expected, however, when confronted by potential calamity of yet-unknown scale. Flattening the curve without too overly heroic interventions was the way to go — again, in hindsight — and, to the credit of most Western cultures, societies and polities, that was indeed the way we went.
Cooler heads prevailed. Not entirely, as Amy indicated — but at least somewhat if not mostly.
What should not be expected or tolerated, on the other hand, are ideologically entrenched ruinous policies. Policies such as implemented in totalitarian contexts like China’s and Russia’s. For while Western policies are not likely to reflect utter ideological absurdity anytime real soon — we are neither inured nor nearly as immune as we once were.
Confounded as it was with an outlandish spike in pneumonia, the extent to which Covid actively existed in Russia’s totalitarian context remains unclear. As for those few Russian citizens that might too obstinately have sought greater clarity, chances of more violent demise than from Covid were extremely elevated. Meanwhile in China, Covid’s ideological inadmissibility — 0-Covid, right? — may ultimately lead to social, political and economic collapse. On all fronts.
We cannot yet compete with such absurdities in the West. Not yet on that scale — though not for lack of trying, either.
For instance, thanks to Sabizabulin — an experimental drug pioneered by a US-based company — patients interred in ICUs at imminent threat of Covid and several other co-morbidities death were lately afforded increased survival hopes. Increased by as much as 50%. This was not in dispute. Yet, even should some future Covid variant once more completely flood ICUs with victims, none shall be spared by Sabizabulin administration. Two weeks ago an advisory committee of the American FDA denied Sabizabulin authorization for just emergency life-saving use.
Why? Many reasons were bandied at the committee meeting. For instance, that there was not enough sample-size data — though the trial had been ended as soon as efficacy was shown to be undeniably, robustly significant statistically. How could any mortality study continue once a drug is shown to be singularly life-saving? How can mere placebos continue to be administered once it becomes known that doing so may often prove equivalent to a death sentence? Further, that the drug mechanism was not fully well understood. But that’s ridiculous. Statistical trials are not required when causal mechanisms are fully well understood. They are required to test efficacy and safety in spite of our causal ignorance. It has even been suggested there was some conflict of interest at the meeting — that one or more of the committee members were entangled with rival pharmas that stand to lose market share in event Sabizabulin were granted any use authorization.
None of this can account for blocking an undisputedly, singularly life-saving drug. Not if saving lives were the foremost criterion. But it was not. Clearly not, as members continued raising ludicrous concerns. Why were people of colour not more prominent among the critically ill studied? What if ICU patients somehow coerced information from medical staff regarding whether their drips were administered the drug or placebo? What if there were “unknown unknowns” that yet systematically defeated randomization — as if any sample size could guard against such causal villainy. Certainly, had ICU patients become aware and mutinied from the placebo group, randomization could have been defeated. But had patients been able to coerce information or capable of mutiny they would not have been ICU interred in the first place.
The argument that seemed to sway the committee against authorization most was that the small sample size could not eliminate the possibility of some rare reactions to the drug reducing safety — however marginally. And, even though no sample size can entirely eliminate the rarest events, this was a telling argument. Telling, that is, until one recalls the subject was a singularly life-saving drug. What sense can there be in not administering a singular life-saving drug because there just might be some vanishingly rare complications or side-effects?
That’s the crux. None of the objections voiced could have been taken seriously if undeniably robust life saving had taken precedence over the mere possibility of complications. Instead? The ineliminable mere possibility of complications took precedence. Arguably, this was not a result restricted to some peculiarity of the FDA advisory committee. Rather, this has become endemic — more so than Covid, yet — to our Western culture. No longer able to distinguish rights from privilege, we now regard safety among fundamental rights. Threats to our safety strike us as worse than death.
Some hysteria should be expected in dire circumstance. But this apparent, emerging Western ideology that absolute safety constitutes a fundamental right? This begins challenging Russian pneumonia and China’s 0-Covid in terms of absurdity.
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[Amy] Wow, love: you go right for the jugular …
[Peter] Should I be going for other body parts instead? Kneecaps?
[Amy] Hmm. I guess it’s become my view that polarized, too-high-energy diatribes have become part of the problem.
[Peter] Well, I was aiming for clarity and validity with a dash of entertaining verve. How did I manage to diatribe instead?
[Amy] You are always entertaining. But I was thinking of all the scare-quotes (e.g., ‘science table’) and overuse of the word ‘hysteria.’
[Peter] Mmm-hmmm. All one of the scare quotes indeed. And yeah, I may have engaged in some hysterical repetition.. but in fairness, some selective repetition is just a motif-ating device. I latched onto ‘hysteria’ that way some.. but also to ‘in hindsight’, for instance. Just something to bring a little more internal structure for the rest of us who don’t write quite as brilliantly lol.
[Amy] Okay. Hmm. Well, there are plenty of things we agree on. I’ll just register, first, that I thought the Science Table did important work during the pandemic.
I’m neutral about whether it should have been disbanded—I am always in favour of expert advisory bodies that provide useful input—but am aware there were multiple exigencies, including a desire to emerge from Covid-only thinking (e.g., of the sort that ignored the long-predicted risk RSV would pose this fall)—but think we’ve both made the point that balanced, nuanced perspectives and policies might have gotten us further than urgent pendulum swings in one direction or other.
You might want to respond with a different point, but I know one thing we’ve talked about is whether there are epidemiological ecologies we might have paid better attention to—perhaps more ‘natural’ (to use scare-quotes) ways of responding to Covid.
[Peter] I was highly unimpressed with the science table. There can’t be much doubt members were selected on basis of political compliance and compatibility — there’s much greater variance in what scientists and even medical professionals would otherwise have advocated. It isn’t the job of science to arrive at definitive policy conclusions. To the contrary — the job of science is to refute what’s evidently false. And yes, absolutely agreed viral ecology under pressure from vaccination ought to have been thought about far more. To what extent have we been grooming way more vicious variants under vaccination pressure? Ought we have protected relatively benign Omicron variant — maximized spread to provide it with as much advantage over competing strains as possible? But, of course, that’s no matter for a ‘science table’ to even conceive exploring. They were just there to provide extra veneers of authority and deniability.
[Amy] Okay. I don’t share this view at all. The Science Table was appointed by the Province—if they were selected for their compliance, why was there so much discord? Me, I think that’s a good thing. The Science Table wasn’t a group of apologists, that’s for sure.
Me, I think the Science Table was disbanded not because it didn’t do an effective job but because the Province believed it had served its purpose, and that it was important to shift toward post-pandemic policies. Opinions differ about this, of course, but it’s true that we are in a post-pandemic environment, especially in the sense that the viruses of concern this fall are not (only) Covid, whose levels seem to have remained relatively static in recent months, but the regular old, bad old RSV and seasonal flu—whose harm has been multiplied because people remained somewhat single-mindedly fixated on Covid.
As for vaccines, we differ on this. I don’t think vaccination prevented us from getting down with Omicron—I think it likely that Omicron seemed too mild because, by the time it appeared, most of the global population had already been vaccinated or exposed to previous variants or both.
[Peter] Ok, I don’t want to argue about this too much. I think science table membership was a function of political more than scientific appointment. With agenda set in advance — most un-scientific. And of course they weren’t compliant — they were ambitious administrators provided with a one-time opportunity to throw their weight around as leaders mantled in scientific authority. Gah. As for the viral ecology at large, I believe fears are rising of more vicious, vaccine evading variants. As vaccines accelerate already leaping viral evolution (as with antibiotics and everything bacterial), our best protection is in partnership with the existing strains already committed and able to begin collaborating with us not as their disposable hosts but, perhaps eventually, as commensals. Not to say that any ever-more-benign Covid variant will become indispensable as our mitochondria at any far future point — but who knows. Let’s not seek to eradicate the variants we’ve already at endemic truce with. And, not just incidentally — can you imagine anything of this sort ever getting raised, considered or even imagined at the ‘science table’?
[Amy] So, I’m not an epidemiologist, and neither are you. But from my citizen’s understanding of vaccines—not just Covid vaccines but all the many vaccines that have been developed over the last couple of centuries—they are precisely a negotiation with the natural. Vaccines stimulate our immune systems to recognise and respond to viruses. They don’t weaken the immune system—to the contrary, they strengthen it.
[Peter] Interjecting from downstairs — hope this syncs…. Yeah.. well, the similarity between today’s vaccines and yesteryear’s is in name only. We’re not swallowing soaked in formaldehyde and thereby inactivated / killed viruses here. Nowadays vaccines are incredibly targeted to specific viral protein finger prints. Which raises at least 3 sorts of vital questions. Do we really want to clutter and potentially confuse our immune systems with such specific, non-generalizing, brittle instructions — leading to requiring endless boostering while potentially actually weakening (confusing) resistance and immunity? And, to what extent are m--RNA vaccines mutagenic to us in hitherto unprecedented Bladerunner ways? And, to what extent do so finely targeted immune instructions actually accelerate already rapid evolving viral variance? If you think this last is no great concern just Google ‘fear’ and ‘vaccine evading Covid variants’. Stands to reason, right? The tiniest mutation away from any specific protein fingerprint can produce the most tremendous advantage for the virus. What would otherwise vanish as without advantage or even consequence, like most mutations, becomes a potential viral tide instead. Anyway — aren’t we way off topic now? I do appreciate most of what I just said may seem like yet more conspiracy theories.. but maybe that’s just as well.
[Amy] Huh. I guess I see the ‘vaccines are causing Cold War-style escalation with virus variants’ crowd as being basically at an adjacent campsite to the ‘variants are the fault of people who don’t wear N95 masks every time they leave the house’ group. One view tends to be promoted by the ideological right; the other by the ideological left. Both camps might be right—but only in the meaningless sense that viruses generate variants. Viruses gonna virus. That’s what they do. And the presence or absence of vaccines, or the use or nonuse of masks hasn’t likely affected that process all that much. I think we agree that there has been no such thing as a remotely effective Zero Covid strategy. But it’s not really about the virus or its variants so much—it’s about what humans do to deal with it. And in this respect, Covid vaccines have been a medical triumph.
From what I understand about Covid vaccines, their strength—at least in terms of the ecological negotiation you argue we need to better protect against future variants—may be that Covid vaccines don’t protect entirely against Covid. Plenty of vaccinated people have still gotten Covid, only with mild or asymptomatic illness. Contrary to some claims, there is no evidence Covid vaccines are propelling Covid to produce greater and more elaborate variants. Covid has been quite successful in making itself endemic, and through a combination of vaccination and exposure, the global population is now able to deal with it. Just as we do with seasonal influenza—which, every now and again pumps out a new variant, against which flu vaccines provide adequate protection.
At risk of going on too long—but I do want to respond to your points—it’s my sense that fears about the mRNA nature of Covid vaccines involve a misunderstanding of how both vaccines and genetics work. The science behind mRNA vaccines has reportedly been around for decades and mRNA vaccine research was progressing promisingly well before the Covid pandemic began. Worries that mRNA vaccines will change or damage our genome seem a bit strange to me, given that almost everything affects gene expression—sunlight, background radiation from the bricks in our buildings, the food we eat, whether we smoke, the kind and amount of exercise we get, and so on and so forth. This fear reminds me of anti-GMO food activism a few years ago when, despite evidence to the contrary (and despite the reality that every potato, banana and grain we consume has had its genome vastly altered over the last 10,000 years or so via selective breeding, and despite the fact that most corn, and soy products on the market were bioengineered decade/s ago), fearmongers claimed transgenic foods would … well, I’m not quite sure. Change our DNA? Tamper with Mother Nature? Something along those lines. Meanwhile, numerous drugs and medical treatments have since as far back as the 1980s involved recombinant ingredients—some of the more common GMO-derived drugs include insulin and Hepatitis B vaccines. And, heck, the ovulation stimulating drug I took back in 2007 contained genes from some small mammal, and I have never once felt the urge to run around a hamster wheel in the middle of the night.
[Peter] Hilarious.. but missing the points I was suggesting. Sure, in one sense the science behind m-RNA vaccines has long been around. What hasn’t is much appreciation how powerful a back door to genetic redesignation — desireable or otherwise — m-RNA manipulation may provide. Not that long ago DNA and RNA were thought categorically distinct. Not so much any more. And some vaccines are yet more genetically activating — using viral vectors to alter genetic expression at the root. Altering human cells genetically to produce characteristic viral proteins which will then train our immune systems to specifically recognize, respond, attack. Any event, I’m not saying let’s not play with this fire. To the contrary. My issue is is with the specificity — it’s not how our immune systems have evolved to respond and work. To the contrary — this is more like forcing an infant to always repeat the same phrase. Bad idea if seeking to encourage communication and expression more generally. It’s brittle, anti-organic and will require infinite boosting to remain effective. Like forcing said infant to keep memorizing new phrases. While it becomes increasingly unable to express anything creatively beyond the information already given. But that’s it for me.. we need some guidance to keep from getting this far off topic.
[Amy] One thing I know we agree on entirely is that human activities should, wherever possible, respect the natural. Me, I’m more of an interventionist where medical treatments are concerned—you have concerns about mRNA drugs that mess with our genome, while I’m all for recombinant drugs that might cure AIDS and Ebola and a big fan of complex immunotherapies that promise viable treatments for devastating cancers. For your part, you are cool with space colonies I don’t think humans have earned the right to establish, considering what we’ve done to our own planet. We agree that passive cooling is better than running air conditioning in the summer, and we are happy only to gas up the car once every two or three months. We both care deeply about keeping our carbon footprint small. I think we also agree that the most unnatural thing about the pandemic hasn’t been the virus, or the drugs developed to treat it. Rather, the most unnatural thing about the pandemic has been the collateral damage to children, namely the prolonged, extreme and unreasonable isolation that has cost an entire generation of kids years of learning and social development, and which has predictably led to the current surge in RSV and seasonal flu cases at a time when hospitals are completely unequipped to handle the surge.
[Peter] Wow. Amazing. You brought us back to topic. How’d you manage that??
[Amy] …
[Postscript: Look at us! We managed to have a civil conversation about a controversial subject on which we have differing views, without coming to blows or threatening divorce even once. What readers may not know is that, during the hours over which this conversation unfolded, we also managed to walk our two cats, share eldercare duties, care for our sick-with-a-miserable-cold kid, schedule grocery-getting, monitor the stock market (Peter) and row six kilometres (Amy). Today also marks exactly twenty years since we first met, so happy arguing anniversary to us!]