As the coronavirus outbreak spreads into rural parts of the United
States, more people who live far from a hospital are increasingly likely
to need one. That poses challenges for communities where hospitals are
scarce and I.C.U. beds are in short supply — even a relatively small
outbreak there could overwhelm medical resources, with potentially grim
consequences for public health.
Research shows people are less likely to seek health care, even
emergency care, when they need to travel farther to get it, especially
when they are more than about 30 minutes from a hospital.
“We already know that people in rural regions who are located farther
from health care use care less and generally have worse outcomes,” said
Dr. Paul Delamater, a researcher on health care access at the University
of North Carolina.
And that’s under normal circumstances. In a pandemic, the problem is
twofold. Without a hospital nearby, those who are sick may not seek care
at all, leaving them to suffer and to risk spreading the infection to
others.
But if a large outbreak does occur and too many people need treatment,
rural hospitals could easily be overwhelmed and be forced to send
patients traveling even farther from their homes for care.
“I would imagine things are only going to get worse, not better,” Dr. Delamater said.
,
many of them in the Southeast. In the West, there have been fewer
closures, but hospitals are more dispersed and many are designated “
,”
with 25 or fewer inpatient beds. That means fewer beds, farther apart
for the sick, whether those with coronavirus or those needing other
treatment.
The problem of distance is further compounded by demographics. Rural
populations generally tend to be older and have higher rates of
underlying health conditions, making them most at risk of
hospitalization from the coronavirus.
Alpine County, which straddles the Sierra Nevada in Northern
California, is one of more than 700 counties nationwide with no hospital
at all. The closest is in South Lake Tahoe, a 30- to 40-minute drive
for most residents, according to Nichole Williamson, the county’s
director for Health and Human Services.
Just one person in the county has tested positive for coronavirus so
far, but if the outbreak were to grow, Ms. Williamson said, there would
not be much they could do. A shortage of medical personnel means that
setting up a temporary hospital would not be an option. “We have plenty
of buildings we could use,” she said, “but we don’t have the staff to
open up an alternate care site.”
Ms. Williamson said that if an outbreak occurred in Alpine County, she
would expect people would need to be sent to a bigger hospital in Reno,
Nev., about an hour and 15 minutes away.
. Evidence is also building that people who might have otherwise gone in for conditions unrelated to the coronavirus are
So far, those outcomes are a risk but not yet a reality in most rural
areas. In some counties with the largest populations living far from
hospitals, local officials said they had not heard of anyone failing to
get the medical treatment they needed.
In Whatcom County, Wash., for example, 38,000 people live 30 or more
minutes from St. Joseph Medical Center in Bellingham. Cindy
Hollinsworth, an expert in communicable diseases at the county health
department, said that even though many residents did not live within
that range, all lived within a 40-minute drive and had access to
emergency medical services.
A spokesman for San Bernardino County, Calif., where there are 24
hospitals but 61,000 residents still live outside the 30-minute range,
said the current public health concern there was a shortage of tests for
the virus, not hospital beds.
But some areas of the country with large populations living far from
hospitals are showing cause for concern. Rural communities in three
states where the coronavirus has spread — Arizona, Florida and
Washington — are already experiencing strain on their local medical
facilities.
remote landscape, about half a million people live more than a
30-minute drive from the nearest hospital. Access is especially
difficult in Native American tribal areas, where coronavirus cases are
growing quickly.
An outbreak that began in mid-March had reached 350 infections just in Navajo County as
Anne Newland, who operates primary care clinics across Northern
Arizona, said smaller tribal clinics were already reaching capacity and
transferring patients who needed intensive care to facilities in
Flagstaff and Phoenix.
“In Navajo County, they’re trying to get patients who need a ventilator
out,” she said. “Patients from these highly affected areas are able to
be transferred down to the valley, but that’s an expense.”
Patient transfers can cost up to $20,000, an overwhelming burden for
smaller facilities. “Covid-19 is just a condition that’s challenging
everybody,” Dr. Newland said.
She also worries that given the severity of the outbreak, people will be hesitant to travel long distances to hospitals at all.
“It’s not just the distance, it’s that people are afraid,” she said.
“And sometimes they need to see their doctor or go into the E.R., and
they shouldn't avoid that.”
, hospital access is the most limited in the farm towns of the panhandle and north of the Everglades.
The lack of a nearby hospital in Immokalee, a migrant farming town of 24,000 in South Florida, creates
under normal circumstances and is causing greater concern as the coronavirus pandemic unfolds. As of Friday, 34
Workers there produce most of the state’s tomato supply. They have
called for a field hospital to be set up in town through the Coalition
of Immokalee Workers, a labor advocacy and human rights group.
“We’re about 40 minutes to an hour to a hospital, so that's going to be
very limiting,” said Lupe Gonzalo, a farm worker and staff member of
the coalition.
Farm workers are deemed essential workers, but they lack protective
equipment, and for many workers social distancing is impractical.
“The buses they ride on to go to the farms are packed, sometimes with
over 40 or 50 people,” Mrs. Gonzalo said. “The workers live in confined
spaces — maybe 10 to 15 people in a trailer. So if one person gets sick,
many people will get sick.”
State, rural hospitals are seeing problems with too few patients rather
than too many. Nonurgent procedures are suspended, and people with
chronic conditions are avoiding going to the hospital.
“We are actually seeing people delay care that’s kind of concerning
right now,” said Jacqueline Barton True, the vice president of rural
health programs at the Washington State Hospital Association.
Ms. Barton True said at least six critically ill patients had had to be
airlifted from rural Columbia County since the last week of March, an
unusually high number, and none of them with coronavirus.
All over the state, rural hospitals that canceled elective surgeries to
keep beds open for coronavirus patients have taken a heavy financial
hit. On Wednesday, a spokeswoman for the Three Rivers Hospital in
Brewster said they had just 51 days of cash on hand.
“The most vulnerable rural hospitals are hardest hit by the inability
to generate revenue,” Becky Bennett, a spokeswoman for the state health
department, said.
Despite some federal aid, there’s growing concern over whether these
hospitals will be able to weather the crisis in the long term. Advance
payments from Medicare have helped, Ms. Barton True said, but “that
money will have to be paid back in a number of months, and a lot of our
hospitals are very concerned about how and whether they’re going to be
able to pay that money back.”
,
where the U.S. outbreak first began, they are still rising in some
rural counties, such as Douglas, though in far smaller numbers. The
state is able to run 21,000 tests for the virus each day, but in Kitsap
County and other rural areas, health care providers said they were still
being told to prioritize testing for high-risk groups, not everyone who
may have symptoms.
Steve Metcalf, a spokesman for the Tacoma-Pierce County Health
Department, said it was still possible that hospitals there could face
problems with capacity. “When the time comes to reduce social distancing
— we are not there yet — we anticipate there could be a bounce in cases
at local hospitals,” he said.
NOTE: The reality is that many health professionals in
the United States have already left medicine. At least, they have left
direct patient care for one of the many administrative positions that
exist in our highly bureaucratic and complex market-driven system.
Even before the pandemic, the healthcare system in the United States
was broken. Physician burnout was rising and a new term entered the
field, “moral injury,” a term typically reserved for soldiers in the
military. How long can one last in a system that runs counter to
everything you were trained to do – to provide care to patients?
So many changes need to be made right now, and as soon as we realize
they aren’t going to be made unless we make them and that we have the
power to make them, we can get to the work of creating a society that
supports life instead of allowing the making of profits in a system that
is designed to extinguish life, whether directly or indirectly. – MF
One ER physician recounts the stress of constant intubations and PPE shortages.
I couldn’t see. My face shield was blurred by a streaky haze. I
tilted my neck back and forth in an effort to peer beyond it, beneath
it, through it, whatever might work. Was it condensation? I started to
raise my hands to my face to wipe it away before I remembered and yanked
them back down: I cannot touch my face, can’t ever touch my face —
neither inside this room nor outside it.
As I stood at the head of the patient’s bed in ER Room 3, her nurse,
Kate, secured a mask over the patient’s face to deliver additional
oxygen. I checked to ensure the oxygen was cranked up to the maximum
flow rate while we waited for the respiratory therapist. Even with that
increased oxygen, the patient was saturating 85% at best, and her blood
pressure was dropping.
Ninety minutes earlier, the patient — a woman of 68 years with
significant impairment from a stroke — had been fine. The nurse at her
nursing home called to inform us they were sending the patient to the ER
for evaluation of “altered mental status” because she was less “perky”
than usual. Her oxygen level on arrival was normal with no shortness of
breath. Her blood pressure was a little low, but her blood glucose read
high. Nothing a little IV fluid couldn’t fix, and initially, it did.
I had requested a rectal temperature; it read 103 degrees. The
combination of her being a nursing home resident and running a fever was
a red flag during these coronavirus times. I placed her on respiratory
isolation and asked Kate to be extra vigilant for any decline. I ordered
broad-spectrum antibiotics to kill any likely source of infection while
I awaited her chest X-ray, urine, and blood tests. Her portable chest
X-ray was done first and revealed what I had already anticipated:
diffuse atypical infiltrates, a presumed telltale sign of Covid-19.
Although our understanding of this viral infection is ever-evolving, it
seems the only observation we can reliably conclude is that we have not
yet identified anything pathognomonic about it.
Seventy-five minutes later, another nurse, Charlene, called, “They need you in Room 3.”
“Okay,” I replied as I entered orders on the next chest pain patient with shortness of breath.
“Dr. Harper, they need you in Room 3 now,” Charlene called again.
“Room 3? The nursing home patient? I’ll be right there. What happened?”
“Her oxygen is at 67%.”
I asked the clerk to call respiratory therapy for intubation. I then
turned back to Charlene to ask her to help Kate prepare for the
procedure.
Then the personal protective equipment (PPE) sequence. I grabbed
gloves to remove my N95 mask from its paper bag and placed it over my
face, checking it was snug over my nose and lower jaw. After removing
those gloves, I donned my face shield, then walked to the cart for a new
gown. Lastly, a fresh set of gloves before entering the patient’s room.
Now I waited for the respiratory therapist. It was good that she
needed extra time to get the ventilator and then don her PPE because I
had to figure out why I couldn’t see without manually manipulating my
face shield. My thoughts were pierced by the sound of panting. I checked
the patient who was taking the oxygen quietly, rapidly, ineffectively
at regular intervals that didn’t register a sound. Her eyes remained
closed—no flip of an eyelash, no wince of her forehead, no twitch in a
limb. Despite her instability, the patient was in no visible distress.
No heaving breath there. The nurse to my left was concentrating on the
patient’s oxygen. I heard only the crinkle of her gown as she adjusted
her stance. The panting wasn’t hers. The nurse to my right prepared to
administer the intubation medications. He read out my orders — the name
and dose of the medication in each syringe and the order in which they
were to be pushed. His voice was steady. It wasn’t him hyperventilating.
The nurse just outside of the room kept documentation of the procedure
on scrap paper she used to carefully transcribe each detail onto her
laptop. She was too far away to be heard unless she yelled, so that
audible breathing certainly wasn’t hers.
The panting was my own.
A hailstorm of thoughts ensued. Was my breath the fog on my face
shield? If so, my N95 mask had a leak. Unsuspecting, had I already
inhaled the virus? Would I be intubated next?
The respiratory therapist had arrived with the ventilator and put on
her face shield. She was almost ready, so there was little time to pull
myself together.
Breathe in, I commanded myself: One, two, three. Breathe out. I obeyed: One, two, three, four.
Was I already short of breath? Had I not noticed my symptoms when I drove to work this morning? Yesterday? Last night?
Breathe in. One two, three. Breathe out. One, two, three, four.
I was scared, and I don’t get scared. Other doctors do, but not ER
doctors. We don’t scare easily. We’re a type of special forces who step
in when everything else has failed. Typically, we do our job anonymously
then leave when the mission is complete. Any injury to ourselves
incurred in the line of duty is dealt with after we’re off the clock.
Once in a while, however, there are circumstances when the capacity
to compartmentalize is overwhelmed, when the chronic stress breaks
through so that the fear works on you. Now, as I stood at the patient’s
bed with the video laryngoscope blade in one hand and the endotracheal
tube in the other, panic pushed its way through me in involuntary.
forceful. rapid. shallow. breaths.
Breathe in on one, two, three. Breathe out on one, two, three, four.
The respiratory therapist slapped on her gloves and in moments was at my side. It was time for intubation.
Breathe in on three and out on four.
At last, my breathing was smooth, measured, sound.
I looked through my mask again. It wasn’t condensation. It was
streaks from the sanitizing wipes because we had to reuse our equipment.
I adjusted my eyes to the clear spaces. Finally I could see. My N95 mask fit. I could breathe.
The room was relatively quiet, what I like to call “ER calm.” All was
still, save for the bagging of respiratory therapy, save for the swoosh
of oxygen jetting from its port aerosolizing everything.
I requested that the intubation medications be administered then
checked for a response. After visualizing the vocal cords easily with
the video laryngoscope, I slid in the endotracheal tube, and respiratory
connected it to the vent. The patient’s oxygen increased to 100% on the
monitor.
Doffing my gown and gloves, I put on new gloves to remove and
sanitize my face shield. I couldn’t imagine there was a way to
effectively clean the foam band across the forehead. I hoped to remove
the streaks. I also hoped the impossible: to remove the virus, because
it was the same shield I had to use repeatedly during my shift. I took
off the N95. We’re now told that we can reuse it, too, numerous times
before getting a new one due to the PPE shortages, so I put the
contaminated mask back in the bag until I would need to don it again for
the next patient.
This is how we get infected. This is how we die.
Those of us who survive will return each day to battle because we do
not walk away from war until it’s done. But when this war is over, this
is why many of us will leave.
I walked to the back of the ER to use the restroom in the seven
minutes before the patient was ready for CT and saw my ER director
standing in the lounge. I waved hello.
“How did it go?” she asked, her eyes gentle, her smile sympathetic.
“It went,” I replied.
“How did you feel in the PPE? Did you feel protected?”
I paused to regulate my answer. Her intentions were good. She was an
ER doctor who did her best to walk the fine line between the docs on the
front lines and the administrators who notified me that “doctors don’t
get paid sick leave” and “thank you for your service,” which were
graciously sent out in two separate emails. Just another reminder that
we health care providers are regarded as more disposable than our PPE.
But this wasn’t her fault, so I felt responsible, in that moment, for
her feelings too.
I pulled in my tone. “No. That equipment doesn’t protect us. There’s
no way that we’re not all covered in Covid, but we’re following the
‘guidelines.’”
She nodded and frowned.
“Honestly,” I continued, “and I hate to say this, but my feeling is
that the majority of people will have contracted this virus. Most people
will get through it, and others won’t. Many will die. I don’t want any
of us to die, but many health care providers will. The thing is, it’s
impossible to know which camp we’re in until it happens.”
She nodded again.
We smiled at each other, and I continued to the bathroom. I washed my
hands, turning them over each other, lathering the soap along each
finger, under each nail. As I dried my hands, I looked up at the mirror,
noting that my breath was now imperceptible when my phone rang.
A FaceTime request from my nine-year-old nephew, Eli.
My policy used to be to not answer the phone at work unless it was
critical. But this is a different era. Eli is sheltering-in-place at a
military base in California while his mother, my sister, is away for
deployment.
I swiped the phone to answer. “Hi, Eli!”
“Hello, Aunt,” he announced more softly than usual. His eyelids hovered low, and his eyes weren’t their typical bright.
“How are you, Eli?” I inquired, masking my concern.
“I’m good.” He smiled with sleepy eyes. “I just woke up.” He yawned,
his bushy eyebrows raised high. Years ago, he said his eyebrows were the
indisputable evidence that Frida Kahlo was his great, great grandmother
so he had to meet her forthwith. Upon being told that she had already
passed away, he cried for the woman he had decided was his long-lost
ancestor. Now, as he yawned again, his thick eyelashes shut tight. His
head drifted back and his mouth reeled open expelling the strongest
exhale of the bravest lion cub.
Today we are OK.
Michele Harper is an emergency room physician for
more than a decade and author of the upcoming memoir, The Beauty in
Breaking. For more information visit: micheleharper.com.
https://popularresistance.org/when-this-war-is-over-many-of-us-will-leave-medicine/
Top E.R. Doctor Who Treated Virus Patients Dies by Suicide
“She
tried to do her job, and it killed her,” said the father of Dr. Lorna
M.reen, who worked at a Manhattan hospital hit hard by the coronavirus
outbreak.
A top emergency room doctor at a Manhattan hospital that treated
many coronavirus patients died by suicide on Sunday, her father and the
police said.
Dr. Lorna M. Breen, the medical director
of the emergency department at NewYork-Presbyterian Allen Hospital, died
in Charlottesville, Va., where she was staying with family, her father
said in an interview.
Tyler Hawn, a spokesman for the
Charlottesville Police Department, said in an email that officers on
Sunday responded to a call seeking medical assistance.
“The victim was taken to U.V.A. Hospital for treatment, but later succumbed to self-inflicted injuries,” Mr. Hawn said.
Dr. Breen’s father, Dr. Philip C. Breen, said she had described devastating scenes of the toll the coronavirus took on patients.
“She tried to do her job, and it killed her,” he said.
The
elder Dr. Breen said his daughter had contracted the coronavirus but
had gone back to work after recuperating for about a week and a half.
The hospital sent her home again, before her family intervened to bring
her to Charlottesville, he said.
Dr. Breen, 49,
did not have a history of mental illness, her father said. But he said
that when he last spoke with her, she seemed detached, and he could tell
something was wrong. She had described to him an onslaught of patients
who were dying before they could even be taken out of ambulances.
“She was truly in the trenches of the front line,” he said.
He added: “Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who has died.”
In
a statement, NewYork-Presbyterian/Columbia used that language to
describe her. “Dr. Breen is a hero who brought the highest ideals of
medicine to the challenging front lines of the emergency department,”
the statement said. “Our focus today is to provide support to her
family, friends and colleagues as they cope with this news during what
is already an extraordinarily difficult time.”
Dr.
Angela Mills, head of emergency medical services for several
NewYork-Presbyterian campuses, including Allen, sent an email to
hospital staffers on Sunday night informing them of Dr. Breen’s death.
The email, which was reviewed by The New York Times, did not mention a
cause of death. Dr. Mills, who could not be reached for comment, said in
the email that the hospital was deferring to the family’s request for
privacy.
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“A death presents us with many questions that we may not be able to answer,” the email read.
Aside
from work, Dr. Breen filled her time with friends, hobbies and sports,
friends said. She was an avid member of a New York ski club and traveled
regularly out west to ski and snowboard. She was also a deeply
religious Christian who volunteered at a home for older people once a
week, friends said. Once a year, she threw a large party on the roof
deck of her Manhattan home.
She was very close with her sisters and mother, who lived in Virginia.
One
colleague said he had spent dozens of hours talking to Dr. Breen not
only about medicine but about their lives and the hobbies she enjoyed,
which also included salsa dancing. She was a lively presence, outgoing
and extroverted, at work events, the colleague said.
NewYork-Presbyterian
Allen is a 200-bed hospital at the northern tip of Manhattan that at
times had as many as 170 patients with Covid-19, the illness caused by
the coronavirus. As of April 7, there had been 59 patient deaths at the
hospital, according to an internal document.
Dr.
Lawrence A. Melniker, the vice chair for quality care at the
NewYork-Presbyterian Brooklyn Methodist Hospital, said that Dr. Breen
was a well-respected and well-liked doctor in the NewYork-Presbyterian
system, a network of hospitals that includes the Columbia University
Irving Medical Center and the Weill Cornell Medical Center.
“You don’t get to a position like that at Allen without being very talented,” he said.
Dr.
Melniker said the coronavirus had presented unusual mental health
challenges for emergency physicians throughout New York, the epicenter
of the crisis in the United States.
Doctors are
accustomed to responding to all sorts of grisly tragedies, he said. But
rarely do they have to worry about getting sick themselves, or about
infecting their colleagues, friends and family members.
And rarely do they have to treat their own co-workers.
Another
colleague said that Dr. Breen was always looking out for others, making
sure her doctors had protective equipment or whatever else they needed.
Even when she was home recovering from Covid-19, she texted her
co-workers to check in and see how they were doing, the colleague said.
https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html?referringSource=articleShare
‘Afraid to Be a Nurse’: Health Workers Under Attack
Stigmatized as vectors of contagion in some countries, health care workers have been assaulted, abused and ostracized.
By
Kirk Semple - NYT - April 27, 2020
MEXICO CITY — The senior nurse went on national television to make a plea on behalf of her fellow health care workers:
Please stop assaulting us.
Nurses
working under her auspices had been viciously attacked around Mexico at
least 21 times, accused of spreading the coronavirus. Many were no
longer wearing their uniforms as they traveled to or from work for fear
of being hurt, said the official, Fabiana Zepeda Arias, chief of nursing
programs for Mexico’s Social Security Institute.
“We
can save your lives,” she said, addressing the assailants. “Please help
us take care of you, and for that we need you to take care of us.”
In
many cities, doctors, nurses and other health care workers have been
celebrated with choruses of applause and cheers from windows and
rooftops for providing the front-line defense against the pandemic.
But
in some places health care workers, stigmatized as vectors of contagion
because of their work, have been assaulted, abused and ostracized.
In
the Philippines, attackers doused a nurse with bleach, blinding him. In
India, a group of medical workers was chased by a stone-throwing mob.
In Pakistan, a nurse and her children were evicted from their apartment
building.
Dozens of attacks on health care workers have
been reported in Mexico, where intense outbreaks among hospital staff
of Covid-19, the disease caused by the coronavirus, have unnerved
residents and members of the medical community alike. Scores of doctors
and nurses have fallen ill in several hospitals around the country, and
widespread demonstrations have erupted among health care workers
complaining about inadequate protective equipment.
Nurses
in the state of Jalisco reported being blocked from public
transportation because of their occupation. A nurse in Culiacán, the
capital of the state of Sinaloa in Mexico’s northwest, said she was
drenched with chlorine while walking along the street.
In Merida, a city on the Yucatán Peninsula, a nurse said he was hit with an egg thrown by someone passing on a motorcycle.
Ms.
Zepeda Arias, who spoke last week at a news conference, said 21 of her
Social Security Institute nurses had been attacked in the past month.
“It
hurts to talk about this, it hurts to talk about what happens to your
people,” she said, fighting back tears. “Aggression is not something
that anyone wants. We truly invite you to respect us.”
The
attacks against medical workers seem to be rooted in fear and ignorance
fed by misinformation, said Edith Mujica Chávez, the president of the
Inter-Institutional Commission of Nurses in the state of Jalisco.
“It
is understandable, considering how much uncertainty and misinformation
there is out there,” she said in an interview. “You have some people
panicking and locking themselves in their houses, others thinking
nothing will happen to them and going around carefree, and others
thinking it is nurses and doctors who will spread the virus because we
are in contact with patients.”
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Mexico
moved more slowly than other countries in the region to require social
distancing and encourage people to stay home, and the number of
coronavirus cases has risen sharply in recent weeks. On Sunday night,
government officials reported 14,677 confirmed cases in the country and
1,351 deaths.
The authorities have said that the confirmed cases include more than 500 health care workers.
Mexican officials have condemned the aggression against doctors and nurses and characterized the episodes as isolated.
At
a news conference on Friday night, Dr. Hugo López-Gatell, a deputy
health minister, called the attacks and discrimination against medical
crews working to keep the country safe “extremely worrying, absolutely
unacceptable.”
“All of this is inexplicable to a
certain extent, it is surprising,” he said. “Precisely the people who
have the best possibility and the best intention of helping — the health
workers who are on the front line of response — are attacked for the
fact that they are health workers.”
Scattered accounts of hostility have circulated around the world.
In
the Philippines, a nurse in the southern province of Sultan Kudarat was
attacked by five men who thought he was infected with the virus because
of his work. They poured bleach on his face, leaving him with what his
doctors said could be permanent damage to his eyesight.
In
a televised speech this month, the country’s president, Rodrigo
Duterte, warned that people who discriminated against health care
workers would be dealt with swiftly.
“I want to order the police to arrest anyone who harasses them,” he said. “ Once in prison, do not feed them. Let them starve.”
In India, health care workers have reported being physically attacked,
spat at and threatened with sexual violence for treating patients with the coronavirus.
Doctors in protective gear were
chased by a stone-throwing mob early this month in the central city of Indore after they tried to screen a woman for Covid-19.
“They screamed, ‘Catch them! Hit them!’” one of the doctors, Zakia Sayed,
recalled in an interview with India Today, a television network. “We don’t know how and why the situation got so bad.”
Reports
of health care workers being blocked from their homes by fearful
neighbors — or evicted altogether by landlords — have proliferated in
several countries.
Ghazala Bhatti, a nurse in Karachi,
Pakistan, and the mother of three children, said her landlord had asked
her to vacate their apartment because of fears that she would infect
others in the building after treating Covid-19 patients.
“The
landlord told me that he is worried about the health of his 72-year-old
father battling cancer, who also lives on the first floor of the
building,” said Mrs. Bhatti, who moved in with her brother because she
was unable to find a place to rent with the city on lockdown.
“I am heartbroken,” she said. “I have never felt afraid to be a nurse until it happened.”
A doctor at a government hospital in the state of Odisha, in India,
filed a police complaint
against residents of her apartment building after they accused her of
spreading the virus. In her statement, the doctor said one resident
threatened her with rape if she did not move out.
Dr.
Sanjibani Panigrahi, who works at a hospital in the Indian city of
Surat, said neighbors had tried to bar her from entering her building,
telling her she should be “shunted out of society.”
“I
don’t know how long I can stay here,” she said in an interview. “There
is so much panic and hysteria right now. Being a doctor has become a
stigma.”
Reporting was contributed by Paulina Villegas from Mexico
City, Jason Gutierrez from Manila, Zia Ur Rehman from Karachi,
Pakistan, and Kai Schultz from New Delhi.
https://www.nytimes.com/2020/04/27/world/americas/coronavirus-health-workers-attacked.html?action=click&module=Spotlight&pgtype=Homepage
Editor's Note -
This next clipping from The New
Yorker is very, very long, but worth reading in my opinion as it
documents the extent of the pervasive and wide-ranging nature of the intrusion of the profit motive
into the clinical decision-making apparatus, supply chain into the structure of the American
health care system. In many cases putting profit first has replace putting the patient first.
As one commentator put it in an email he sent out:
"On
the individual level, what "the crisis reveals" is that if your skills
are portable, and you can emigrate to a country with a First World
health system, like Thailand, you should. This one's a tear-down."
-SPC
What the Coronavirus Crisis Reveals About American Medicine
Siddhartha Mukherjee - The New Yorker - May 4, 2020
At 4:18
a.m. on February 1, 1997, a fire broke out in the
Aisin Seiki company’s Factory No. 1, in Kariya, a hundred and sixty
miles southwest of Tokyo. Soon, flames had engulfed the plant and
incinerated the production line that made a part called a P-valve—a
device used in vehicles to modulate brake pressure and prevent skidding.
The valve was small and cheap—about the size of a fist, and roughly ten
dollars apiece—but indispensable. The Aisin factory normally produced
almost thirty-three thousand valves a day, and was, at the time, the
exclusive supplier of the part for the Toyota Motor Corporation.
Within
hours, the magnitude of the loss was evident to Toyota. The company had
adopted “just in time” (J.I.T.) production: parts, such as P-valves,
were produced according to immediate needs—to precisely match the number
of vehicles ready for assembly—rather than sitting around in
stockpiles. But the fire had now put the whole enterprise at risk: with
no inventory in the warehouse, there were only enough valves to last a
single day. The production of all Toyota vehicles was about to grind to a
halt. “Such is the fragility of JIT: a surprise event can paralyze
entire networks and even industries,” the management scholars Toshihiro
Nishiguchi and Alexandre Beaudet observed the following year, in a case
study of the episode.
Toyota’s response was extraordinary: by
six-thirty that morning, while the factory was still smoldering,
executives huddled to organize the production of P-valves at other
factories. It was a “war room,” one official recalled. The next day, a
Sunday, small and large factories, some with no direct connection to
Toyota, or even to the automotive industry, received detailed
instructions for manufacturing the P-valves. By February 4th, three days
after the fire, many of these factories had repurposed their machines
to make the valves. Brother Industries, a Japanese company best known
for its sewing machines and typewriters, adapted a computerized milling
device that made typewriter parts to start making P-valves. The ad-hoc
work-around was inefficient—it took fifteen minutes to complete each
valve, its general manager admitted—but the country’s largest company
was in trouble, and so the crisis had become a test of national
solidarity. All in all, Toyota lost some seventy thousand vehicles—an
astonishingly small number, given the millions of orders it fulfilled
that year. By the end of the week, it had increased shifts and
lengthened hours. Within the month, the company had rebounded.
Every
enterprise learns its strengths and weaknesses from an Aisin-fire
moment—from a disaster that spirals out of control. What those of us in
the medical profession have learned from the
COVID-19 crisis
has been dismaying, and on several fronts. Medicine isn’t a doctor with
a black bag, after all; it’s a complex web of systems and processes. It
is a health-care delivery system—providing antibiotics to a child with
strep throat or a new kidney to a patient with renal failure. It is a
research program, guiding discoveries from the lab bench to the bedside.
It is a set of protocols for quality control—from clinical-practice
guidelines to drug and device approvals. And it is a forum for
exchanging information, allowing for continuous improvement in patient
care. In each arena, the pandemic has revealed some strengths—including
frank heroism and ingenuity—but it has also exposed hidden fractures,
silent aneurysms, points of fragility. Systems that we thought were
homeostatic—self-regulating, self-correcting, like a human body in good
health—turned out to be exquisitely sensitive to turbulence, like the
body during critical illness. Everyone now asks: When will things get
back to normal? But, as a physician and researcher, I fear that the
resumption of normality would signal a failure to learn. We need to
think not about resumption but about revision.
Start with health
care as a delivery system. In this state of emergency, delivering care
has required both personal protective equipment (masks, gowns, gloves)
for medical personnel and devices (including supplemental oxygen and
ventilators) for patients. In the absence of effective drugs, care is
mainly supportive. As the pandemic advanced, the delivery of these goods
to hospitals and clinics should have been akin to a soldierly
deployment, a meticulous, coördinated response—Toyota reassembling a
supply chain within a matter of days. Instead, the medical
infrastructure of one of the world’s wealthiest nations fell apart, like
a slapdash house built by one of the three little pigs.
N95 respirators,
those heavy-duty face masks with two straps and a metal nose bridge,
are a case in point. Before the pandemic, each cost between fifty cents
and a dollar or so. They come in various sizes and styles, and every
year health-care workers have their size “fit tested,” to make sure that
air can’t get in around the edges. (A puff of aerosolized saccharin
might be sprayed near your face; if you can detect the sweetness, the
mask isn’t fitting properly.) The N95, meant for a single use, is
designed to filter particulates as small as 0.3 microns in diameter. In
the pre-pandemic world, when I encountered a patient suspected of having
influenza or TB, say, I would put one on, and discard it in the
biohazard trash after each use.
But mid-crisis, when the need for these masks in hospitals and clinics was most acute, doctors and nurses ran short.
An anesthesiologist from New Jersey told me that he was forced to reuse
his mask for the whole day: “We get one, per shift, per day.” His
nursing staff, he said, initially got none. A resident in Boston who
worked in an E.R. told me that he had no N95 mask until the end of
March; the few that were available were reserved for medical staff
performing intubations and bronchoscopies—procedures that can send viral
particles airborne, and pose the highest risk of infection. He recalled
seeing a patient with symptoms that could have signalled COVID-19:
“When I went to examine him, I had a surgical mask”—a simple clothlike
cover, leaky at the sides—“and a face shield I had been cleaning and
reusing for a month.”
We’ve all heard stories about the absence of
masks in hospitals; we know that their production was typically
outsourced to suppliers in China, which were buffeted by the very
contagion that made these devices so necessary. Meanwhile, the shortage
of these mass-manufactured fifty-cent items has imperilled the safety of
our medical personnel. The question is: Why? Days after the Aisin fire,
a typewriter factory was putting out brake-system components. Why
weren’t our suppliers responding with the same urgency and resilience?
The
story of Mike Bowen, a manufacturer in North Richland Hills, Texas,
offers some clues. His company, Prestige Ameritech, which he and his
partners started fifteen years ago, is among the country’s largest
domestic manufacturers of surgical and N95 masks. Because companies that
moved manufacturing abroad—including Bowen’s old employer,
Kimberly-Clark—would undercut him on price, he often had a hard time
landing orders. “Hospitals typically don’t order masks as individual
buyers,” he told me. He spoke deliberately, with the slightest Texan
drawl. Instead, they negotiate contracts as members of a Group
Purchasing Organization—representing hundreds or thousands of
hospitals—and, as Bowen explained, the G.P.O. always “chooses the
cheapest bid.” His business struggled. In 2009, though, preparations
were made for the H1N1 influenza pandemic, and Bowen was asked to ramp
up his production of face masks to meet the anticipated demand. “We
bought the old Kimberly-Clark factory,” he recalled. “We outfitted it
with new machines. We hired an extra hundred and fifty people. And then,
when it ended, the whole thing fell apart. The people that we helped
went back to the foreign-made masks. So we had to lay off all of those
people.” Bowen almost went bankrupt. “Hospitals promised to retain us as
suppliers after the flu.” But promises are not contracts. “We were just
naïve,” he said.
Bowen kept thinking about
the next pandemic, when the supply of masks from China might plummet and
the demand for domestic masks might surge again. He sent letters
warning about a potential supply-chain problem to President Obama in
2010, and to
President Trump
in 2017; he wrote to the Defense Secretary; to hospital-safety
associations; to officials at the Centers for Disease Control—hundreds
of letters in all. He must have seemed, at times, like an obsessive
crank. “I got a form letter from the White House, thanking me for my
concerns,” he said. “Everybody ignored it.”
When
COVID-19
hit, China shut down many of its factories, and retained most of its
diminished production of masks for its own use. For a while, exports
declined to a trickle. Today, Bowen’s company has increased its
manufacturing almost fourfold, producing at least a million masks a day.
But that’s only a fraction of the demand; he has had to turn away
orders for hundreds of millions a day.
There’s another place that
hospitals and clinics could have looked to for masks, gloves, and gowns:
the Strategic National Stockpile—a repository of emergency equipment
that can be deployed on short notice during a crisis. On March 4th, six
weeks after the first case of
COVID-19 had been reported in
America, the S.N.S. announced its intention to buy six hundred million
N95 respirators in the next eighteen months. Even if private-sector
orders were cancelled when the pandemic subsided, the contracted
companies—Honeywell, Dräger, 3M, Moldex, and O&M Halyard—would thus
have a guaranteed buyer. But pandemics don’t go on hiatus for eighteen
months, patiently waiting for medical supplies to accumulate. The day
after the S.N.S. announcement, the state of Massachusetts requested
seven hundred and fifty thousand N95 masks (and a similar number of
surgical gowns and gloves) to protect its doctors and nurses. Two weeks
passed—each bringing grim news of viral spread—before the state received
a tenth of that number.
When I e-mailed the Strategic National Stockpile, a spokesperson emphasized that the role of the S.N.S. was “to
supplement”—her
emphasis—“state and local supplies during public-health emergencies,”
not to fulfill everyone’s needs. But how many N95s were there in the
stockpile to start with? The answer was thirteen million. New York and
California, between them, have about three million health-care workers.
If a fifth of that workforce were involved in some contact with
virus-infected patients, and if no more than two N95 masks were used per
worker each day, the entire S.N.S. supply would last eleven days.
Our
delivery mechanisms have also broken down for the people trying to
measure and manage the crisis. In this effort, the most important tool
is the detection kit. At a population level, detection enables
mapmaking: quantifying the size and the sources of an infection and
tracking its movements. For an individual patient, it enables
plan-making: assessing whether you’ve been infected and should be
isolated, and tracing whom you’ve put at risk. In the later stages of a
pandemic, the ability to test on a wide scale allows agencies to
concentrate on hot spots and contain them with limited, local lockdowns.
The
C.D.C., which had known about the Wuhan outbreak since December,
started making detection kits in January. According to reporting from
the Washington
Post, on February 8th, one of the first
C.D.C.-made detection kits for the new coronavirus, freshly approved by
the Food and Drug Administration, arrived at a public-health lab in
Manhattan; it contained a set of chemicals, or reagents, meant to
isolate the virus’s genetic material, and a set of three “probes” to
amplify the material and then determine whether it was from the
coronavirus. Time and again, technicians in New York found, one of the
probes—probe N3—registered false positives: even distilled water
triggered a positive result.
As the days dragged by, researchers
at the C.D.C. tried to rejigger the test and make sure that its results
were reliable. (The F.D.A. says that the original design it approved had
performed well; the trouble arose when additional lots of the kit were
manufactured.) Although the World Health Organization had distributed a
quarter of a million tests, manufactured by a German lab and widely used
elsewhere, the F.D.A. had authorized only the C.D.C. kit. When labs at
American hospitals and elsewhere devised detection assays of their own,
the agency prohibited their use until an “Emergency Use Authorization”
had been applied for and granted.
The
“Emergency Use Authorization” protocol, less demanding than the
ordinary approval process, was designed to make the agency nimbler,
while preventing people from peddling useless tests, drugs, or devices
during an emergency. Yet, for some researchers, it would prove to be a
roadblock in itself.
I spoke to Alex Greninger, the assistant
director of the virology lab at the University of Washington. It’s one
of the largest virology labs in the country, and researchers there began
developing a test just days after the first case of
covid-19
was detected on American soil—a thirty-five-year-old man who appeared at
a clinic in Snohomish County, Washington, on January 19th, coughing and
feverish.
Greninger, a square-jawed athletic figure who favors
hoodies over suits, didn’t blame anyone at the C.D.C. or the F.D.A.; in
fact, he told me that he found the officials “extremely responsive and
easy to work with.” As he described the situation, it was the
process that failed. For Greninger’s team, devising a lab test for the new coronavirus,
SARS-CoV-2,
wasn’t particularly difficult: its genomic sequence was already
available, which made it possible to design the right probe for
detecting the viral material. Securing samples of that material to
validate the test wasn’t easy, but Greninger found a way. The next step
was getting the F.D.A. to permit its use. He and his colleagues spent
almost a hundred hours filling out a baroque, thirty-page form, filing
the authorization request on February 19th. Still no dice: he had
e-mailed the material, and the F.D.A. insisted that he print it out and
mail a hard copy, along with the digital file in physical form, such as a
thumb drive or a CD, to a separate “documentation” office. (This
requirement was later withdrawn.)
“They worked as efficiently as
they could,” Greninger said, “but the hard copies probably increased the
turnaround by several additional days.” (The F.D.A. says that, on the
contrary, it reviewed the electronic application immediately.) What gave
the matter particular urgency is that the bulk of patient testing is
done by commercial clinical labs or academic labs, and the C.D.C.
initially distributed its kits only to “C.D.C.-authorized” military and
state and county public-health labs, which do a fraction of over-all
testing. Meanwhile, the infection spread on flights and in movie
theatres and during visits to grandparents, seeding itself in other
cities and states: New York, New Jersey, Louisiana, Connecticut. Yet, by
the last week of February, only a few hundred tests per day were being
performed. On February 28th, Greninger and colleagues sent a letter to
Congress, noting, “No test manufacturer or clinical laboratory has
successfully navigated the E.U.A. process for
SARS-CoV-2 to date.”
The
next day, the F.D.A. relaxed its position, allowing “high complexity”
clinical labs to test for virus infection in advance of agency review
and approval. A simplified E.U.A. form was soon made available.
Greninger e-mailed me two versions of the E.U.A. application. The
original one, from January 19th, was thirty pages and filled with dense
boilerplate. “In the first version,” Greninger told me, “they suggested
the lab test twenty-five positive cases. But when we were looking at
this, in mid-February, there were only fourteen confirmed cases in the
U.S.” This posed a metaphysical question: How can one validate an
emergency test before an emergency occurs? The F.D.A. duly worked with
the C.D.C. and the N.I.H. to make more viral samples available,
lowering the hurdles for test validation without compromising the
quality of the test. A later version of the E.U.A. form, from March 7th,
was just seven pages. Between February 28th and March 1st, Greninger’s
team worked around the clock to prepare the virology lab for testing
hundreds of patient samples. By Monday, March 2nd, the lab had begun its
first tests. A full forty-three days had passed since that
covid-19 patient turned up in Snohomish County.
This
is hardly the first time that the F.D.A. has faced the challenge of
finding the right balance between safety and speed. In October of 1988,
fifteen hundred aids protesters from the direct-action group ACT UP
arrived at the agency to stage a “takeover.” While agency scientists,
horrified and confused, peered out of their windows, activists draped
banners and put out tombstone-shaped signs. (“RIP: killed by the f.d.a.”) As the H.I.V./aids researcher and activist Mark Harrington recounted, it was part of act up’s “Drugs Into Bodies” agenda, propelled by an urgent logic: aids
was nearly always fatal, and time-consuming precautions seemed the
opposite of cautious—patients were being protected to death. The logic
sank in. One way that the F.D.A. eventually responded was by developing
an “accelerated approval” process. It would permit the use of
“surrogate” metrics to judge the success of a medicine; that is, rather
than waiting to measure patient survival rate over some period of time,
researchers could establish effectiveness simply by documenting a
decrease in viral loads, or the recovery of the immune system. Trials
became leaner and swifter, expediting the development and approval of
the antiviral “cocktail” therapies that are now used to treat patients
with H.I.V.
For COVID-19, in turn, the F.D.A. has sought
to fast-forward trials by means of its Coronavirus Treatment
Acceleration Program, working with developers of treatments and
vaccines. Still, the speedier approach has its own pitfalls: it makes it
easier for products that are marginally effective—or outright
ineffective—to slip into the system. “Drugs Into Bodies” too easily
devolves into bad drugs delivered into vulnerable bodies. The same
applies to devices and detection assays. A recent fiasco in the U.K.
illustrates the point: the government spent twenty million dollars on COVID-19 tests, peddled by two Chinese companies, that proved unreliable.
As
Greninger was quick to point out, without some F.D.A. approval process,
testing could become a free-for-all. And in the aftermath of the
testing debacle we’re seeing a pendulum shift toward underregulation.
The F.D.A. has allowed more than ninety companies to offer antibody
tests meant to determine whether someone has already been infected and
possibly acquired immunity. But it has reviewed and authorized only
four. In short, the F.D.A. has essentially recused itself from
evaluating these tests before they come on the market. Poorly regulated
and unreliable tests, could, unfortunately, complicate recovery. Some
nations, such as Italy and the U.K., are considering giving
return-to-work “immunity passports” to those who have antibodies against
the virus. This is a divisive, ethically fraught approach to begin
with. Add in diagnostic errors, and it could be a lethal one.
Tests,
drugs, devices, procedures: all these draw on medicine as a research
program. Major innovations in clinical care are often driven by
scientists working with cell cultures, animal models, and even
computational models—work done in vitro, in vivo, in silico. Lifesaving
treatments found in I.V. bags and pill bottles generally had their
origins in petri dishes and microarrays. Scant the lab research, and a
patient will pay the price.
“I am busier than I have ever been,”
Susan Weiss, a professor of microbiology at the University of
Pennsylvania, told me. Instantly recognizable in the long passageways of
the lab by her nimbus of curly brown hair, she has spent her career
working on coronaviruses. While other labs at the university are under
lockdown, hers is now in hyperdrive: she is studying coronavirus
proteins and their interaction with the human immune system—a topic she
has pursued for forty years. Her work has helped that of other Penn
scientists, including the virologist Sara Cherry, who are searching for
drugs that might block coronaviruses from entering cells and
replicating.
But this flurry of attention was preceded by a long
period of neglect. “Just a few decades ago, we were on the periphery,
even among virologists,” Weiss told me. The first coronavirus conference
was organized in 1980, in Würzburg, Germany. There were sixty people at
the conference—“virtually the entire coronavirus group at that time.”
Federal grants were scarce, and her lab, along with the small band of researchers, struggled for decades with minimal funding. Then, in 2003, SARS hit. “And, of course, suddenly everyone was interested,” Weiss recalled.That September, the National Institutes of Health put out a “Request for Applications” to study SARS.
The N.I.H. organized workshops featuring “international experts in the
fields of coronavirus biology,” and blue-ribbon panels on topics like
“priority pathogens,” biodefense, and vaccines.
“We were suddenly in the middle of all attention,” Weiss said. Then SARS stopped spreading, and the interest evaporated.
But surely, I asked Weiss, someone should have anticipated that another similar pandemic might arise?
“You would think so, wouldn’t you?” Weiss said, her voice tightening in indignation. “You would think
so.” If the research on coronaviruses had kept pace, we might have had
an array of treatment options, even a vaccine platform that could be
adapted for the coronavirus now circulating, a cousin of the one that
causes SARS.
I searched a database called Grantome to
confirm Weiss’s observations. The plot of federal grants awarded for
coronavirus research in the past few decades looks like a bell-shaped
curve. In the nineteen-nineties and early two-thousands, there were
typically between twenty and thirty such grants a year; these were the
lean decades that Weiss had referred to. Predictably, the number surged
after 2003, when SARS arrived, reaching its peak of a hundred
and three in 2008. And then came the decline. This year, no doubt, the
line will rise again.
“The investigators came and then they left,”
Stanley Perlman, a microbiologist at the University of Iowa, told me.
He’s another veteran coronavirus researcher who has watched labs drift
away from his field of concern.
To be fair, the N.I.H. awards most
of its grants based on unsolicited applications it receives from
scientists, and it must balance national priorities. “Look, we live in
uncertain times,” Michael Lauer, a senior administrator at the N.I.H.,
said. “The N.I.H. cannot predict pandemics any more than anyone else
can.” And, he stressed, “there’s already an internal effort to maintain a
diverse portfolio within the Institutes. The whole of the N.I.H.
evaluates its entire portfolio every five years. And some of the grants
build the infrastructure to pay for clinical trials that can be rapidly
deployed during a pandemic”—a network of clinicians who can move as a
body when needed.
Still, the bell-shaped curve of coronavirus
funding nagged at me. Boom-and-bust cycles in research have
consequences: lab technicians are skilled workers who are laid off or
retrained as priorities shift. When I worked in a viral immunology lab
as a grad student at Oxford, our research infrastructure was supported
by dozens of technicians, each trained one-on-one by yet another layer
of skilled technicians. It was a product of time and the accretion of
expertise. A well-run, focussed lab is like a village, not a Quonset hut
you can put up overnight.
What’s more, it was known that SARS and MERS
were deadly coronaviruses with animal reservoirs that could hop to
humans. Disease modellers had determined that a respiratory virus with
modes of transmission similar to SARS-CoV-2 was a likely
culprit in a future pandemic. Why wasn’t our research investment
remotely commensurate with our threat assessments?
On
Sunday, April 4th, Tatiana Prowell, a doctor at Johns Hopkins, messaged
me on Twitter. She forwarded an e-mail from a radiologist in Los
Angeles, along with a CT scan of a young patient’s lung, with a
golf-ball-size clot. An unusual finding was cropping up in patients with
severe
SARS-CoV-2 infections: blood clots in the lung, called
pulmonary emboli (P.E.s), and strokes caused by clots in the brain. Some
were tiny, nearly undetectable, and some were huge. “I think this is a
major unrecognized cause of mortality,” Prowell wrote. “My phone is full
of msgs from physicians from every specialty asking if others are also
seeing unexpected thromboembolic events in young, healthy patients with
COVID-19.
Neurologists getting consulted for stroke, cardiologists finding large
clots on echocardiograms, nephrologists noticing dialysis catheters
clotting, radiologists finding PEs on scans. I think there is a slow
collective awakening to the fact that this is not an isolated
phenomenon.”
In fact, the “slow collective” awakening was already
well under way—elsewhere. Chinese doctors had apparently seen such blood
clots, and started giving patients blood thinners to prevent them.
(“Why are American doctors so resistant to learning from excellent
Chinese doctors who . . . have been on the front line longer,” someone
admonished me on Twitter.) One patient—a man in his twenties—texted me a
picture of bluish spots on his thighs, evidently a scattering of
minuscule clots in the skin. I e-mailed a doctor in London; in
autopsies, he told me, “we are finding micro-emboli, small clots, in the
lungs.” During the next few days, my in-box and my Twitter feed brimmed
with notes from doctors and researchers remarking on these findings,
and wondering about trials for virus-infected patients and blood
thinners.
Is
this loose, informal transmission of anecdotal findings—call it
chatter, call it rumor—part of medicine? It isn’t what anyone is taught
in medical school; it doesn’t fit in with the professional’s image as a
purveyor of rigorously tested interventions. But continuous, iterative
clinical knowledge—the kind that can be updated minute by minute—is
invaluable during this tumult, when time is of the essence and there’s
scant research to fall back on. Such updates are like weather reports in
the middle of a storm. They matter in the moment; once the storm
passes, they’re yesterday’s news.
COVID-19 has similarities to
familiar conditions, but it is a new condition and, like all new
conditions, it has its peculiarities. When doctors exchange notes on
their experiences—about an odd incidence of blood clots, about a
ventilator setting that seems easier on the lungs, about the results of
putting patients in a prone position in order to ease breathing—they can
adjust treatments and improve patient outcomes. Not every provisional
finding will pan out. Medical chatter can prove misguided, just as
there’s plenty of bunk in open research archives. Still, anecdotal
patterns can lay the groundwork for a case series, and then a
case-control study, and, ultimately, a randomized, controlled trial of a
clinical approach. Already, observations that began as scattered tweets
about emboli in
COVID-19 cases have migrated into preprint journal articles, Webinars, and official recommendations from professional bodies.
The
way clinicians have made use of Twitter and Facebook during this crisis
has been a heartening development. We’ve cobbled together an informal
medical bulletin board for the pandemic; even as we wade through the
muddy slop of fake news, we have a forum of exchange that is flexible,
versatile, and timely. This is a story of something that’s gone
right—and of something that’s gone very wrong.
That’s because
clinical medicine is, among other things, an information system, and a
central part of that system is broken. Patient records that once were
scribbled on clipboards now sit in
electronic medical-record (E.M.R.) systems,
many of them provided by the Wisconsin-based software company Epic. A
standardized digital database of patient-care records, searchable across
hospital and medical-care systems, could be an invaluable way of
identifying effective approaches to a novel disease—like moving from a
patchwork meteorological system where towns keep their own records of
wind and rainfall to a national weather-tracking grid. A putative
advantage of digital hospital records is to enable on-the-fly
searches—not the kind of data project that the N.I.H. might fund (its
grants take weeks to process even on an accelerated schedule) but the
kind that might be completed in an hour. Perhaps, I thought, we should
be advising
COVID-19 patients to call us if they suspected
clots—if their breathing rate and heart rate increased suddenly, for
instance. Perhaps our hospital system’s emergency department should be
alerted.
Because clotting is a frequent issue among patients with
cancers, I called my colleague Azra Raza, the director of Columbia’s
Myelodysplastic Syndrome Center, to ask if we could search through the
database of her patients for any who had reported being infected, and,
if so, had experienced blood clots. She sighed. “I can’t think of a
simple way to do this,” she told me. “And in any case, because of all
the concerns around privacy, if you wanted to report the findings you
would have to file with the institutional review board.”
“But that
would take a month, at least,” I protested. (In recent weeks, many
hospitals have accelerated their review process to deal with the pace of
the pandemic.)
“It’s the way the system is,” she said. “If you
want to report the number of times a patient has cut her nails in the
last week, you would need approval. And it’s not easy at all to search
the E.M.R. for any of this information. You’d have to hire someone
specifically to look through it.”
A cardiologist at Massachusetts
General Hospital, in Boston, echoed this frustration on Twitter: “Why
are nearly all notes in Epic . . . basically *useless* to understand
what’s happening to patient during hospital course?” Another doctor’s
reply: “Because notes are used to bill, determine level of service, and
document it rather than their intended purpose, which was to convey our
observations, assessment, and plan. Our important work has been co-opted
by billing.”
The promise of bringing medical recordkeeping into
the digital age was to maintain a live record of a live patient,
enabling clinicians to track patient care across hospital systems and
over time. Instead, we’ve been saddled with systems that cut into
patient care (clinicians typically spend an hour feeding documentation
into a computer for every hour they spend with patients) and, often, are
too fragmented to allow a patient’s file to follow her from one medical
center to another. The E.M.R., as a colleague of mine put it, is
“electronic in the same sense that your grandfather’s radio is
electronic.” The energized, improvisatory role of medical Twitter
inevitably draws attention to what our balky, billion-dollar systems
should have been providing—to the cost, in dollars and lives, of the
rapid clinical learning that we’ve forgone.
It’s hardly news that
our E.M.R. systems have failed medicine, and yet an executive order from
New York State, issued at the end of March by Governor
Andrew Cuomo,
amounted to a grim epitaph: “Health care providers are relieved of
recordkeeping requirements to the extent necessary for health care
providers to perform tasks as may be necessary to respond to the
COVID-19
outbreak. . . . Any person acting reasonably and in good faith under
this provision shall be afforded absolute immunity from liability.” A
system designed to expedite and improve the delivery of health care was
officially recognized as an obstacle.
“When
the tide goes out,” Warren Buffett once said, “you discover who has been
swimming naked.” The pandemic has been merciless in what it has
exposed. In many cases, the weaknesses in our medical system were ones
that had already been the subject of widespread attention, such as the
national scandal of health-care coverage that leaves millions of
Americans uninsured. In others, they should have been the
subject of widespread attention, because we had plenty of warning. Again
and again, in the past several weeks, we’ve heard of
shortages—shortages of protective gear, of ventilators, of
pharmaceuticals. Yet, even before the crisis, medicine was dealing with
troubling scarcities of needed drugs and support systems. Last summer,
long before the pandemic, pulmonologists were raising concerns about a
lack of oxygen supplies—the result of cost-cutting measures by suppliers
of durable medical equipment. Competitive-bidding programs drove
margins down so low that more than forty per cent of such
companies—responsible for the supply of portable oxygen tanks and
concentrators—went out of business. Inventory diminished; delivery times
increased. Patients suffered. Neeta Thakur, a pulmonologist and
researcher at the University of California in San Francisco, told me
about the byzantine process (involving “ten to fifteen disconnected
steps”) that was required in order for a patient to receive oxygen at
home—a patient who is then at the mercy of the intermittent delivery
schedules of understocked venders. The problem builds into a failure
cascade: if patients cannot be discharged from the hospital because they
cannot have oxygen at home, the resultant logjam delays the treatment
of other patients who need those beds for acute care.
The
pharmaceutical system was clearly fraying as well. Vincristine, which I
use to treat blood cancers, was among a hundred important drugs that
have been in critically short supply in recent years. Even bags of
sterile saline solution—the most basic I.V. fluid, nothing more than
salt and water—were hard to source. (Many American hospitals used bags
made by a single manufacturer, in Puerto Rico, which was devastated by
Hurricane Maria.) An F.D.A. report published in October noted that
manufacturers had little incentive to produce less profitable drugs;
that the market failed to reward “ ‘mature quality systems’ that focus
on continuous improvement and early detection of supply chain issues”;
and that “logistical and regulatory challenges make it difficult for the
market to recover from a disruption.” If one factory went offline, the
entire nation’s supply of a critical drug could be imperilled.
As
such pre-pandemic stories proliferate, they point toward more
fundamental reckonings. Leave aside the tragedies of those who died
alone in isolation rooms in hospitals, or of the disproportionate
disease burden borne by African-Americans and working-class immigrants.
Leave aside the windblown avenues of an empty, joyless city, the
generation-defining joblessness that has shifted so many from precarity
to outright peril. To what extent did the market-driven,
efficiency-obsessed culture of hospital administration contribute to the
crisis? Questions about “best practices” in management have become
questions about best practices in public health. The numbers in the bean
counter’s ledger are now body counts in a morgue.
For decades,
consultants had taught the virtues of taut business practices.
“Slack”—underutilized resources, inventory waiting to be put to use—was
shunned. I spoke to David Simchi-Levi, an M.I.T. professor who studies
supply-chain economics and how enterprises respond to disasters. “Cost
is easy to measure,” he told me. “But resilience is much harder.” So we
reward managers for efficiencies—and overlook any attendant fragilities.
His view can be summarized simply: we’ve been overtaught to be
overtaut.
“We’ve been teaching these finance guys how to squeeze,”
Willy Shih, an operations expert at Harvard Business School, told me,
emphasizing the word. “Squeeze more efficiency, squeeze cost, squeeze
more products out at the same cost, squeeze out storage costs, squeeze
out inventory. We really need to educate them about the value of slack.”
Simchi-Levi
is particularly interested in two variables that could serve as metrics
for resilience. The first is the “time to survive”; that is, how long
can an enterprise endure when there’s a sudden shortage of some critical
good? The second is the “time to recover”: how much time will it take
to restore adequate supplies of some critical good? By quantifying each
variable under different scenarios, a business can model its ability to
recover from a disaster. He told me about floods in Thailand that shut
down factories responsible for critical computer and automotive parts.
Afterward, some companies expanded their supply lines to other parts of
Asia. Having seen the fragility of a tight chain, those companies had
now established a network with some spring in it. In the future, their
“time to survive” would exceed the suppliers’ “time to recover.”
Toyota’s
recovery from the Aisin factory fire in 1997 can sound like a story of
triumph, as, in many respects, it was. But the company’s executives
realized that it was also a story of failure. The company shouldn’t have
been so vulnerable to such an event. The fire, along with a later
disaster—the 2011 earthquake, which cut off its supply of a crucial
microchip—taught Toyota the value of redundancy and risk assessment. It
modified its just-in-time system to allow for at least a month’s worth
of specialized components, building strategic slack into its operation.
It created a database, called Rescue, with dozens of companies
organized into tiers, their risks regularly evaluated under conditions
of adversity, and information on sixty-eight hundred parts continually
updated. The company maintains constant communication with its suppliers
under “ordinary operating conditions.” But it also trains employees to
operate during disasters, and evaluates the risk to the entire company
if nodes in the network should falter. No enterprise is truly
disaster-proof, but in cultivating networks of mutual loyalties the
company has engineered resilience.
Yet resilience isn’t simply a
matter of having supplies at hand. In Shih’s view, the most critical
kind of slack doesn’t take the form of a stockpile. Rather, he told me,
“I think of slack as capacity and capabilities.” What you
really want to measure, model, and establish is the capacity to build
something when a crisis arises. And this involves human as well as
physical capital. We need to measure talent, versatility, and
flexibility. Overtaut strings inevitably break.
Resilience in our
medical system will involve more than considerations of physical
supplies. Take the debacle of the C.D.C. detection kit. Here’s where
attention to “mature quality systems” matters. South Korea has so many
test kits that it’s now exporting them for use in the United States.
What was its approach? The government identified more than twenty
reputable venders, certified their products through a sound evaluation
process, and set their factories loose to meet the demand. That’s what
the C.D.C. should have done, long before the pandemic arrived on these
shores. In preparation for a future pandemic, the C.D.C. could run the
equivalent of fire drills, identifying the capacity, almost on the model
of Toyota’s Rescue database, to create and mass-manufacture
such kits during a time of crisis. The organization, rather than closing
itself off, working chiefly with state and military labs, could fortify
lines of communication with the commercial and clinical labs that
actually serve the vast majority of patients. The F.D.A. could have had a
streamlined E.U.A. form already in hand—preferably without a
requirement that it be sent by pigeon post—rather than having labs waste
critical time placating its bureaucracy. Before the next public-health
crisis emerges, the F.D.A. must think hard about how to balance speed
and oversight, adjusting the ratio to meet the moment but abandoning
neither.
Slack can be costly. As Greninger put it, “Right now, I have machines and reagents to test tens of thousands of patients for SARS-CoV-2.
That’s basically all the clinical virology lab is doing. What will
happen when the epidemic is over?” Once the incidence of COVID-19
subsides, so will the sense of urgency when it comes to building
infrastructure, or stockpiling equipment—masks, ventilators,
reagents—that might sit unused in warehouses for a decade or more. We
need purchasing procedures that control costs without creating
conditions in which critical supplies vanish during a crisis. We need a
Strategic National Stockpile that has sufficient inventory to ease
temporary shortages. But, most of all, we need an identified capacity—a
network that can be activated on demand, repurposing manufacturing
lines, recalibrating agency protocols.
In research, too, we need
strategic reserves and cultivated capacities: a scientific
infrastructure directed at our existential threats—categories of
pathogens with the potential to disrupt human communities en masse. This
may require regular “Requests for Applications,” determined by an
advisory panel, that will encourage researchers both to advance our
microbiological understanding of such agents and to develop
interventions and therapeutic platforms. The N.I.H. has many funding
priorities; this agenda must take its place among others. Yet it cannot
be allowed to slip to the margins as ambitious researchers move
toward new areas of excitement. Research does not benefit from a
feast-or-famine ecology.
Finally, we need to acknowledge that our
E.M.R. systems are worse than an infuriating time sink; in times of
crisis, they actively obstruct patient care. We should reimagine the
continuous medical record as its founders first envisaged it: as an
open, searchable library of a patient’s medical life. Think of it as a
kind of intranet: flexible, programmable, easy to use. Right now, its
potential as a resource is blocked, not least by the owners of the
proprietary software, who maintain it as a closed system, and by complex
rules and regulations designed to protect patient privacy. It should be
a simple task to encrypt or remove a patient’s identifying details
while enlisting his or her medical information for the common good. A
storm-forecasting system that warns us after the storm has
passed is useless. What we want is an E.M.R. system that’s versatile
enough to serve as a tool for everyday use but also as a research
application during a crisis, identifying techniques that improve medical
outcomes, and disseminating that information to physicians across the
country in real time.
No set of reforms will deal with every
problem, such as a President who, bickering with scientists, equivocated
and delayed what could have been a lifesaving, economy-protecting,
coördinated response. Given the resolve and the resources, however, much
is within our grasp: a supply chain with adequate, accordioning
capacity; a C.D.C. that can launch pandemic surveillance within days,
not months; research priorities that don’t erase recent history; an
F.D.A. that serves as a checkpoint but not as a roadblock; a digital
system of medical records that provides an aperture to real-time,
practice-guiding information.
“Recovery” is the word of the
moment; it connotes a return to a previous state of well-being. For many
patients with chronic conditions, though, treatment aims not to restore
a baseline of precarious health but to reach a higher baseline. Some of
medicine’s frailties are new; some are of long standing. But what the
pandemic has exposed—call the experience a stress test, a biopsy, or a
full-body CT scan—is painfully clear. Medicine needs to do more than
recover; it needs to get better. ♦
https://www.newyorker.com/magazine/2020/05/04/what-the-coronavirus-crisis-reveals-about-american-medicine?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Magazine_Daily_050420&utm_campaign=aud-dev&utm_medium=email&bxid=5be9f07c24c17c6adf0ccfa8&cndid=20583120&hasha=78202f0b44909bba327f09d42cc6a8da&hashb=cd7a92b1ee2e426b8808faf8f947e22ac0c96fe9&hashc=9b86877134dda0210f2bb0baf6d9faf70229ed5e40cc8f5f9438033dc5964bea&esrc=&utm_term=TNY_Daily
Mukherjee's article should be required reading for every single one of the "suits" and "scarves" who have stood with the dummy-in-chief on the podium at the interminable not-so-briefings airing the Federal incompetent response to the COVID-19 pandemic. The DIC is excused for cause. The exact same obligation should be undertaken by all the immmediate subordinates of the aforementioned suits and scarves, and they should be instructed to undertake their readings in the context of Caper's observations of the intrusion of profit motives (and I would add 'functions') into the provision and oversight of health care in this country.
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