S1E17 / Getting Prepared / John Lynch, Syra Madad, Reid Wilson

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic.

Today is Tuesday, May 5th. In this episode, we're going to hear from two infectious disease specialists who are responsible for preparing hospitals in two of the cities that have been hit early hit earliest and hardest by the coronavirus, Seattle and New York City.

We'll also hear from a journalist who's been digging into what's happening in the interior of the country, to which the epicenter of transmission is shifting.

Dr. Syra Madad is the senior director of the Special Pathogens Program for New York City Health Hospitals. Health Hospitals oversees New York City's 11 public hospitals. A big part of Syra's job has been thinking about the next big threat and what it would be like when New York City faced such a threat from infectious disease. About a year ago, she was thinking about SARS and what would happen if a virus like that came to New York City. So they put together a simulation.

About 8 other countries around the world are also reporting similar outbreaks.

I can't breathe. Part of that exercise was captured in a Netflix documentary called a pandemic, how to prevent an outbreak.

And we don't know the laboratory analysis of this particular outbreak. And we know that we had a number of our emergency department doctors, respiratory therapists, nurses, technicians, and things like that all kind of come together. And we set up a scenario where, you know, it's an unknown novel respiratory virus circulating around the world, a handful of countries. This is going to be a surge event. You have a number of patients, you have healthcare workers coming in. Here at one of our hospitals, ED is full. There's about 8 of them in this trailer, if you will. So this is a trailer on wheels that's completely like an emergency department if you walk in.

They wanted to see how clinicians would react in an unknown scenario, how they'd handle protocols around infection control and personal protective equipment. How they'd handle a surge of patients with little to no information about the virus.

And unfortunately, this is exactly what we're experiencing today with the coronavirus disease.

In this episode, we're going to hear from experts like Syra Madad and others about the importance of hospital preparedness for epidemics.

We're going to hear how simulations like the one that Syra described lay the foundation for healthcare professionals to take action when pandemic strikes. And we're going to look at some parts of the country that haven't had the benefit of such simulations, places like rural America, small-town America. We'll see what they're going to be facing as the pandemic spreads. Now, Saira Madad knows how scary COVID is firsthand.

She's already had it. That's right. I contracted COVID probably about 3 and a half weeks ago, and I lost my sense of taste and smell. Yesterday was the first day where I was able to enjoy a cup of coffee and actually be able to taste and smell it.

On top of that, she recently gave birth to her third child.

So my baby girl is now 3 months old. I have 2 boys, 6 and 4. And so when I was diagnosed with COVID certainly, you know, a scary moment, making sure that knowing you have little kids at home, I also have my husband husband's parents, both high-risk individuals. And so just trying to quarantine myself, but I was also breastfeeding my baby girl at that time. So when I started coming out with my signs and symptoms, I was wearing a mask and gloves. And then once I actually started to have a kind of a high fever, I quarantined myself for a period of time and kind of did the best that I could. But it was certainly a scary time. And luckily everybody in my household recovered and we're all doing fine.

Dealing with a virus that's so contagious you have to wear masks and gloves in your own home while you're caring for your child, that really hits home how important personal protective equipment is in this pandemic. And it was something the simulation showed too.

Really making sure that we have good infection control and that we have different milestones or markers to see, okay, doing a quick PPE check. Am I soiled? Am I contaminated? What do I have to take off right now? The lessons learned that we had in that simulation has really helped in our response and strategy due to COVID-19.

Also how important a clear chain of command was. Their simulation showed that strangers could work well together as long as everyone knew their roles.

These same lessons at an interpersonal level translate to institutions as well. That means setting up an emergency management structure immediately, assigning specific roles, making sure logistics and supply chains are in order, in involving everyone from the largest hospitals to the smallest community clinics that may see COVID cases.

We actually started tracking COVID-19 when the first report hit ProMed in terms of this cluster of pneumonia of unknown etiology. Very early in January, I put together the first meeting with a number of our leadership to talk about, you know, this is something that is very concerning and we need to start preparing for it because it will eventually come to New York City. We know time is not on our side, and we need to make sure that we always act fast and efficiently in order to respond as fast as we can and obviously to make sure that we're saving as many lives as possible.

But this is where New York ran into trouble. Despite all the lessons learned from simulations and other best practices, the city didn't act quite quickly enough. Just a couple days can make a big difference with a virus that spreads exponentially.

Meanwhile, on the other side of the country in Seattle, another team was facing their own coronavirus crisis. The first patient in the United States diagnosed with COVID-19 was in Washington, just north of Seattle on January 19th.

I think up to that point, we've been looking a lot at an epidemic that was happening someplace else. And I think that day was basically just a clear and honest recognition that the containment strategy weren't working.

This is Dr. John Lynch. He's in charge of infection control at Harborview Medical Center in Seattle. John and I go way back. John was one of my seniors when I was an intern, back when we were both residents at Mass General in Boston.

How did that make you feel when you heard about that first case being diagnosed in your own backyard, basically?

Well, it felt like all the work that we've been doing over the past 5 or 6 years— I was grateful that we had it in place. We had done a lot of work with our local public health jurisdiction. So Public Health, Seattle-King County, Drs. Megan Kay and Jeff Duchin, who are amazing public health leaders. We had worked with them back in 2014 around this idea of a home assessment team.

These home assessments were developed as a response to an Ebola outbreak. Basically, medical staff would suit up in PPE and assess potentially infected people in their homes to see if they had Ebola. It turned out not to be needed in that outbreak, but it proved to be great for tracing cases of COVID After the first outbreak, there were at least 68 people who needed to be tested.

We have a team built up of nurses, infection prevention professionals, and physicians, and they'll say, hey, we have someone who was exposed or someone who traveled from this area and now has symptoms that were sort of meeting a case definition for concern. We travel out in a team usually of 5 people. It was a physician and a nurse who would be the 2 people who would go into the house, the hotel room, or the apartment building. And we did all of those— high-rises, regular houses. We would pull up to a site, basically build a donning area and a doffing area.

Donning and doffing is a fancy way of saying putting on and taking off your PPE. It's complicated and it has to be done right.

And we would have a site commander and basically an observation officer who would monitor the actual donning and doffing of the PPE, and then usually a fifth person who would just be a helper and also in training. We built up a really great team of people who could do this on weekends, at nights, during the days, during the weeks, to go out to people's homes and get the samples done, get the samples delivered, and get the results back out to people, all in clear and constant communication with our public health colleagues.

I can tell you from experience that this is basically the same setup we used when I was working in Guinea during the Ebola outbreak.

This worked great, really, up until we had a community outbreak here, until we started seeing a very large number of patients.

Once there was widespread transmission in the community, the team had to change course. Now they needed to prepare the hospitals for a surge of COVID patients.

They set up an emergency command center. There were daily briefings, a lot of the same things that New York recommended after their simulations. They also canceled elective surgeries and moved to telemedicine to try to increase capacity at the hospital. And Seattle had the equivalent of a secret weapon, something that hospital systems all over America and other places did not have. Seattle had the ability to test for the virus.

We got very lucky that our clinical lab medicine colleagues were able to stand up a local test. So starting that Monday night, night after learning about the outbreak basically on Friday, we started testing everyone who's admitted to our facility with respiratory symptoms that Monday night, and it's been going on since then. So we've had access to testing for patients. Shortly thereafter, we were able to get a drive-through clinic like we've seen in many countries in Asia stand up, particularly in South Korea and other places. So lots of patient testing, lots of employee testing.

Another thing Harborview did was to communicate clearly and openly with staff about how COVID is transmitted. And to make sure staff had the personal protective equipment they needed.

And I would say that here, our nurses, our other unionized healthcare workers have recognized that we've been transparent about the data. We've got their back and making sure it's all accessible, that we have, you know, easy access to all the PPE they need. I don't think they've ever felt desperate, like wearing an N95 for a week has never happened here. We've been able to mitigate all that very, very early on because of paying attention to what we truly think is the biology and informing our PPE choices as a result.

Seattle was at the very beginning of the curve. John says that at their peak, they had about 120 patients and it's falling. When we spoke on May 1st, John said that there were roughly 85 patients in their ICU.

The question now is that going to continue to decrease or is it going to stabilize? We're seeing states around the country, including soon here in Washington State, some relaxation of the physical distancing that's gonna be put into place. And we do not know whether we're gonna see cases go down, stabilize, or go up. And until we have some of that experience, we are not going to be able to sort of decide what the true new normal is. But at the very least, it's gonna be lots of universal masking, lots of screening, lots of testing, uh, regular assessments of your healthcare workforce, and ultimately I think we're going to need more people doing this work over time.

So what is this going to look like when the virus starts to reach middle America? Reid Wilson is a reporter with The Hill.

This is a virus that started in epicenters in, in my hometown of Seattle and in New York City and the Bay Area, and since then it has been moving more and more into rural America. Areas where the health system is a lot more vulnerable, where people tend to be older, where people tend to have more underlying conditions. So basically, we're just ripe for more disaster, more death.

Reed knows a thing or two about epidemics. His book, Ebola and the Global Scramble to Prevent the Next Killer Outbreak, is due out in paperback on May 12th. Reed says that the next outbreak might be in rural states that so far have avoided the worst of the COVID crisis.

The states that are seeing the highest percentage of growth are those rural states, Nebraska, Iowa, South Dakota. South Dakota is a fascinating case. You know, South Dakota has something like 1,800 cases, but a very small death rate. Their case fatality rate is under 1%. Well, that's because all these cases have just been diagnosed in the last couple of weeks. So their rate, their case fatality rate is going to rise as more and more people go through this virus.

One reason for this is that social distancing is difficult in rural areas, especially because of the economy. This is why meatpacking plants are now the latest hotspots for COVID.

Especially in places like Iowa, which is pretty heavily dependent on, on meatpacking facilities. I was talking to an epidemiologist at the University of Iowa and she was saying all of the cases in Des Moines are in the southwest corner of the city. Well, who lives there? The immigrants who work in those meatpacking plants. These people are on lines. They're not 6 feet away from each other, I'll tell you that. And there have been even stories about people who are afraid to cough into their elbows or to take the basic precautions that we need to take, because if they do, they might miss a chicken or, you know, whatever's coming down the conveyor belt that they're supposed to do something on, and therefore they'll get a demerit and they'll— they risk losing their jobs. Now, President Trump has ordered the meatpacking plants to stay open to protect the food chain. That's, that's got a lot of people really worried that basically he's sending people to work to guarantee that they're going to get this virus.

Another rural population at risk for coronavirus is Native Americans living on reservations.

The Navajo Nation in particular has just been brutally hit. Its case rate is up there with New York City at its worst. It's not just the Navajo Nation. It's— there are pockets in South Dakota, in Oklahoma. Wyoming's only seen 7 deaths from the coronavirus, but almost all of them are from the Northern Arapaho Tribe.

Reed says that Native American economies are also particularly vulnerable to COVID shocks. Things like natural resource extraction and casinos, for example, have both been very hard hit.

This is like a double whammy for the Native population. These are communities that are very tight-knit. They are very likely to have multi-generational households, so you know, you're living with your kids and your grandparents and your parents all in the same place. And health systems have undergone, you know, what, 2 centuries of underfunding. Native tribes, in a lot of their treaties with the American government, were promised good housing and good healthcare. Well, you won't be surprised to know that we haven't exactly followed through on those promises.

Having spent time working at Indian Health Service hospitals, including just outside the Navajo Nation, I can tell you that the living conditions can be tough. Many homes on the reservation don't have running water or electricity. That can make things like handwashing really hard. Despite the warning signs Reed mentioned, many of the first states to try to reopen their economies are rural states that haven't yet seen large cases of COVID While cities like Detroit, Boston, and New York were seeing a surge in cases, many states in the South and Midwest wondered what all the fuss was about.

And I think that's like totally understandable, right? That's human nature. Well, this thing isn't really coming to my community, so why am I locked down? Why have I lost my job? Why are all the businesses closed?

These states, for better or worse, are going to be canaries in the coal mine when it comes to reopening early and the coronavirus.

There was a great poll out of North Carolina the other day, asked people, if they reopen the economy, what are you gonna do? And as it turns out, you know, fewer than a third are gonna go to a restaurant, and only 9% would go to a movie theater and things like that. So Americans are clearly not ready to get back to normal, whatever our new normal is gonna look like. So let's watch these next 3 weeks. Somebody who ventures out today to a restaurant and gets infected, you know, they might not show up in the data for up to 2 weeks. So as we get to week 2, week 3, we'll see how these sort of mini experiments in reopening are starting to go. If Georgia sees a new surge in cases, if Texas sees a surge in cases, well, then we're going to have to lock down again. If they don't, well, then maybe we can safely reopen.

All these stories show how important it is to be prepared for an epidemic, but it takes resources and political will to support and maintain these programs. So that hospitals across the country are ready when they face an epidemic.

Saira Madad again. When these programs, you know, exist, we need to make sure that they're sustained. Yesterday was Ebola, today it's COVID-19, tomorrow it could be something else. But unfortunately, the approach that we've always had, I think, from the federal standpoint is you're funding these networks and systems for a short period of time and then you're not sustaining them.

This is a persistent problem in public health. There's even a specific name for it. It's called the U-shaped curve of concern. It basically means that governments throw resources at a problem when it's at its worst, but as soon as they start to see improvements, the funding and the attention dries up.

We need to make sure that just because the disease itself may decline due to, you know, public health interventions and the response that we have both at the public health and healthcare delivery level, we need to continue funding these programs. And I think one of the key points is when we talk about funding the hospital preparedness program that helps fund a lot of the resources and the training and helps maintain our state of readiness. That budget has been cut nearly in half from over $500 million in fiscal year 2003 to $265 million in fiscal year '19. So that goes to show you from a national standpoint, we're not investing enough in preparedness. And in fact, we're constantly cutting the funding that is actually available at the local level for these programs. And this is where rubber meets the road. This is where it actually all counts in terms of our preparedness and being able to save as many lives as possible. We want to make sure everybody's prepared because we know COVID-19 is just one epidemic that we're currently facing. There's going to be another one in the pipeline, and we need to make sure that we're investing today for tomorrow.

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I'm Dr. Celine Gounder.

And I'm Ron Klain.

Thanks for listening to Epidemic.