In the midst of the COVID-19 crisis gripping the commonwealth and the country, Dr. Jennifer Leaning, an international public health expert who is professor of the Practice of Health and Human Rights at the Harvard Chan School of Public Health, an associate professor of medicine at Harvard Medical School, former director of the FXB Center at Harvard University, and former active staff at Brigham and Women’s Hospital Department of Emergency Medicine, recently spoke with the Martha’s Vineyard Times on subjects related to the pandemic. Dr. Leaning is a full-time Vineyard resident.
RS: Is one of the dangers of this pathogen that the population hasn’t been exposed to it and therefore doesn’t have any antibodies for it?
JL: Yes. That’s a fundamental problem. And it is a danger. It seems as if most of the human population, and it may be all, but we don’t know what’s happening with everyone, but it seems that most of the human population has not seen this virus before. And that’s why it’s having the capacity to spread but also because a fair number of people get ill. Now thankfully, the majority of people have a very mild illness.
RS: Given that Ebola reared up not that long ago and given a number of serious respiratory ailments cropped up not so long ago, one would have thought that there was a turnkey and well-equipped operational plan for something of the scale of this pandemic. But it looks as though perhaps there isn’t. Is there any easy way to explain that?
JL: Well, there’s a high level simple way to explain it. It’s just that the United States disbanded its pandemic task force and high level disaster think tank within the government in 2018. They ignored a major study that was done in a similar time period that said that the United States needed to prepare for a pandemic and that it was not ready. These are the things that need to be done. That study was ignored. And so I think the federal government had been blindsided by this and could have done a much better job of preparing. But I would say that the preparedness for something on this scale takes a lot of money. And this is always the situation in disasters in terms of anticipating disasters, to be really good at being ready for disasters, whether it’s hurricanes, or pandemics, or floods, one would have to stockpile a lot of material and have it in good shape and ready. And you might not use it for five or 10 years, but it’s there and you have to make sure it’s in good shape, whether it’s life rafts or whether it’s stored water, or whether it’s motorboats. It’s taking care of and tending the large supply chain needed to respond rapidly to a disaster that’s in itself an enterprise and expense. And secondly, you have the whole problem of personnel and manpower — keeping them up to speed, training them, making them on the ready. This is the sort of stuff that the U.S. military is good at but the civilian sector has not had to do this rigorous focus on, not an ordinary event, but on a probable extraordinary event that will happen in a time uncertain. So preparedness for a disaster is always very expensive and no municipality, community, or state, in this country or virtually any country, has really wanted to pay the price to be good at it. But a pandemic has been seen as increasingly likely since the three or four major viral epidemics we’ve had to deal with in the start of the 21st century. And so that it was identified as one of the major threats to the United States should have activated a high level of focus and a commitment of a great deal of money to put us in shape to prepare. And the basic preparedness for a pandemic is to protect your healthcare personnel. And then protect the people whom you need in key areas with sufficient PPE, masks, equipment, etc. And so I would say it’s a failure of judgment, it’s a failure of vision, a failure of will that we’re in this situation.
RS: Based on your experience as an emergency room physician, under non-pandemic circumstances, if you’re working in the ER and someone comes in with what you suspect is an infectious disease like tuberculosis, or let’s say the measles, could you walk through the general protocol?
JL: Well, emergency departments in this country and all sorts of people within the health system around the country require their staff, nurses, secretaries, doctors, managers, store room people, all of them have to be vaccinated for measles and rubella, German Measles. And you have to have that vaccination before you’re allowed to work. And every year you have to have a TB (tuberculosis) test to show that you have not been, in that interim, infected with TB. And so the people who are working in these hospitals and in any sort of connection to healthcare are relatively immune to the walk-in patient with measles or with rubella. With tuberculosis, you have to be more careful because you can be tested to show that you haven’t been exposed to it but there is no vaccination against tuberculosis so if there is if there is a suspicious person from the standpoint of symptoms, living conditions, coming from a country that has a high incidence of active TB and complaining of a cough or fever, the protocol is you immediately, at the front desk, triage, you put a mask on the person, you basically alert the providers that this is a possible tuberculosis case and in addition to everything else and then the whole number of protocols come into play when you go in to talk to them you have a mask on you’re wearing gloves. So in the ordinary set of circumstances in the United States in healthcare we have protocols that protect the provider from getting infected and also protocols that protect the patient if he or she does have the disease or the illness from propagating it to other patients in the emergency department or the triage area or the waiting room. But with coronavirus, this is where in the last month people are getting very good at this in the hospitals. They are doing the triage outside or taking tests to the extent that they have ones with a rapid turnaround. They are saying to people who come in and present themselves [with] a fever and a cough…basically…go home…and come back if you get sicker, because the tests are not available and sufficient. They’re not testing them, they’re just not letting them get into the hospital where they might infect others. So this is a roll-out that’s happening—it is being followed very carefully. So the bottom line is that we are trying very hard at the hospital interface to protect the patients that are in the hospital, to protect the providers, to have the people who come in go back to their homes and self quarantine for 14 days and if they get sicker to come to the emergency department and then they will be admitted quickly. So this is best case. But the numbers are overwhelming hospitals; that’s the problem, the number of serious cases that are now coming in. If you read about it in New York City in parts of California and as it was in Washington state, it’s coming. New Orleans is having…problems. There just aren’t enough beds, aren’t enough doctors; there aren’t enough ICU units. There are certainly not enough ventilators. So [the] protocol is now such that all the hospitals are primarily focusing on the very sick. And that’s why they’re moving the patients who have a broken leg or heart failure or some other issue which could be quite serious…into tents and hospitals, makeshift hospitals that are quite well equipped, but they are not the major hospitals.
RS: How is the Brigham doing?
JL: Brigham is taut and they’re managing, most of the cases are carefully triaged either outside or in the emergency department. Beth Israel, I just heard tonight, has a robot that meets patients outside and does the triage questionnaire and asks these issues and gives some directions about whether to go home or come back early if they get sicker or to go on to the emergency department and then it electronically transmits to the emergency department that this person looks like that have coronavirus and are sick and need to be considered for admission. Most places, including the hospitals here in Falmouth, on Martha’s Vineyard, there are medical personnel doing that triage but also but also subject to some exposure as you know if they touch people. It would be nice to put in a robot, which I think is fabulous. I don’t know how it’s been received by the patients, of course, but it protects the health care personnel and this is one of the points I would like to make about COVID-19—that we have to think about two sets of populations and I’m not alone and saying this. One is the health care personnel. They are a finite set of people and they are increasingly at risk of getting ill and the more healthcare personnel who get ill, they are out of commission for…quarantine or coming back into the hospital and at risk of being seriously ill. So you have people who are put out of service if they catch this illness or come down with it…You’re putting people out of service for at least a month to six weeks and if you start having a large number of people in that setting, you have a dribbling supply of healthcare personnel in the hospital that could take care of people. And this is why it is very important not to overwhelm the hospitals so the providers get sick. And that is what is happening in New York City, and I think it’s at risk of happening in Boston. And so this is the crucial issue here we need to get the testing out fast so that when someone comes in and says I have a fever and a cough and they’re a healthcare provider you can test them and within an hour, minutes or an hour, [learn] they’re not COVID positive it’s not the virus that is getting them. Then that person should probably stay out of work for a few days but they can come back when they can feel better. Right now we put them out for a much longer period of time because we can’t test them. So getting testing capacity is crucial for the healthcare providers. That is very important. And then the other big thing is that we have to be able to take care of the very sick and this is where this whole cry for ventilators and skilled staff, masks to protect the health care providers, really comes in. [T]here are not so many people on the Island…that is true and it’s easier for people to be careful with each other, to self quarantine to self isolate but it’s also important to know that Martha’s Vineyard Hospital is small and not set up to take care of long-stay acute patients. And similarly Falmouth Hospital, an excellent hospital, it’s not that big either so it’s really important to try to stem whatever spread of the virus is already on the Island and not have it be overtaking the population or the hospitals.
RS: What happens if both rural hospitals and the city hospitals become chock-a-block full? Is that a field hospital situation? Is that uncharted territory?
JL: Well, it becomes a field hospital situation in the sense that the triage gets more strict. These protocols have not been widely shared. They may vary from hospital to state to city and that is a problem in itself but this sort of decision making has to be sort of local depending on the competency and depth of your medical stuff, nursing staff and depending upon the skill set of those who are running the ventilators and the rest of the hospital and the numbers it’s got. But essentially the triage rules [change so] you start spending your time on those that are most sick and then when you’re overwhelmed with the number of the most sick—even in taking care of only the most sick you can’t take care of them all—then you have to decide who you do not take care of even though they’re very sick and that is brutal. That is war surgery. That is not usually what happens in peacetime medicine. Most doctors and nurses in the United States have not had to do that kind of triage. You have to go back to World War I, World War II and Vietnam to find physicians and surgeons in the United States who have been confronted with that sort of triage situation, and I fervently hope that we don’t get to that point and as far as I know we’re not yet at that point. That might be ahead but I know that the health authorities, the governors, the mayors, are working very very hard so that we could give very good care to those who are most sick and buttress our chances of survival without doing injury to others who are also sick.
RS: Are you participating in the fight against the pathogen?
JL: Well I’m helping with some people who are doing large scale studies of population movement and assessment of contagion. I’m not remotely the data person, but I’m in the background and helping to think through some of the options. And there are a number of other studies that are going on primarily through the Harvard system that I’m aware of but not participating in. But I’m working with colleagues on other topics and they sort of cross-talk about what they are doing so I’m fairly informed. But I’m here on the Island in self isolation and for some reason it’s the busiest time of my life. I mean there are so many things, so many people to talk to, and papers that are being written, and research discussions, etcetera. So, it is intellectually, medically, scientifically, an extraordinarily busy time. So many good minds trying to figure out possibilities for this. But at the same time there are really amazingly grave, I mean I’m not surprised, but I’m impressed by the clinicians, doctors, nurses, and others, who are taking care of patients and they still don’t have the right PPE, still don’t have a fresh mask for different patients, most of them have gloves, but they don’t have sufficient gowns, or scrub changes, and they are exposing themselves to the risk of getting this disease every time they walk into a patient room or every time they see them in the emergency department. It is essential, a priority now, to protect the health professionals because we’re no where nearer the peak, as Charlie Baker is saying, and I think the data he is using is pretty reliable… he’s predicting somewhere between mid 70s to 140,000 nationally by mid April. So we are nowhere near that capacity to handle that number. I’ll just say that. That the emergency departments and the hospitals in the greater Boston area are already working terribly hard and in New York City they are already saying that they are not sure they are going to be able to cope.
RS: How are you keeping safe and preventing spread on a personal level?
JL: I am playing it very safe. I am in the age group with documented higher mortality (over 65) and although I am healthy, inevitably my age diminishes the strength of my immune system. You cannot control that one. So although I have considerable confidence in my capacity to fight illness or disease, I am listening to the experts, and convinced by the repeated epidemiological evidence from every country with this pandemic, that older people are at considerably greater risk of dying from this virus. Not necessarily at great risk of getting the virus in the first place, however. So I am trying to reduce that latter risk—of getting the disease—as much as possible. I am wearing a good mask whenever I go out. And I go “out” very rarely. I take vigorous walks along a route where others are not walking much at all; I lift some weights at home. So I try to stay fit, even get more fit! I have a lot of writing and interacting to do with others at Harvard and elsewhere in the world so I am on Zoom and email and phone and What’s App and trying to think and make progress on a number of articles, chapters. So my mind is more than occupied. Reading a book is a great pleasure for which I still do not give myself enough time. The complication, however, is that I live with my partner who still has to work at one of the hospitals she is attached to — the other has allowed her to do telemedicine at home. So at the other hospital she is being very careful but other clinicians with whom she works — i.e. inhabits the same rather large spaces and corridors [with] — have tested positive and gone home, the ones I know about, are recovering. So she is subject to some unmeasurable scale of risk for getting the virus that is, however, higher than my risk in my current environment. So we inhabit different floors of the house, meeting carefully and at some distance in the shared spaces.
Lightly edited for clarity.