Public Health Threats and Pandemics
Vanessa B. Kerry, co-founder and CEO of Seed Global Health, and Craig Spencer, director of global health for the department of emergency medicine at New York Presbyterian/Columbia University Medical Center, discuss COVID-19 and how state and local officials can respond to protect their communities as part of CFR’s State and Local Officials conference call series.
Learn more about CFR’s State and Local Officials Initiative.
Co-founder and CEO, Seed Global Health; Director, Global Public Policy and Social Change, Harvard Medical School
Director of Global Health, New York Presbyterian/Columbia University Medical Center Department of Emergency Medicine
FASKIANOS: Good afternoon from New York. And welcome to the Council on Foreign Relations State and Local Officials Conference Call Series. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR.
We’re delighted to have participants from forty-three states across the country on today’s call, which is on the record. As you know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. Through our State and Local Officials Initiative we serve as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. We produce Foreign Affairs magazine, and also briefings with CFR fellows.
We know that many of you on the call today are on the frontlines of responding to COVID-19, which is why we have convened today’s call with Dr. Vanessa Kerry and Dr. Craig Spencer. We shared their full bios prior to the call, so I’ll just give you a few highlights on their distinguished backgrounds.
Dr. Vanessa Kerry is the founder and CEO of Seed Global Health, a nonprofit that invests in health care systems strengthening by training needed health professionals in resource-limited settings. She’s the director of the program in global public policy and social change in the Department of Global Health and Social Medicine at Harvard’s Medical School. And she is a physician at Massachusetts General Hospital and serves as the associate director of partnerships and global initiatives at the hospital’s Center for Global Health.
Dr. Craig Spencer is the director of global health and emergency medicine at New York Presbyterian Columbia University Medical Center. He currently divides his time between providing clinical care in New York and working internationally in public health. Dr. Spencer has worked as a field epidemiologist on numerous projects, including with Doctors Without Borders on the Ebola outbreak in Guinea.
So welcome to both of you. Thank you very much for taking time out of your busy schedules to be with us and to talk to everybody on the call. Craig Spencer, I thought we would first begin with you. Just give us an update on COVID-19, what you’re seeing in New York ER rooms, and any best practices you would like to share as you’re navigating through this.
SPENCER: Great, Irina. Thanks so much for having me on the call. And thanks to everyone for taking time out of your days, which must be also incredibly busy right now with preparations. I think the best way that we’re going to get through this as a country is through combined preparation, centralizing our resources, and really learning the lessons unlearned from China, from Italy, and, quite frankly, from the outbreak that we’re having right now in New York City.
What I’m going to share, it’s certainly not meant to incite panic but really to speed up our preparedness. I can’t state this forcefully enough: The virus is here. It’s spreading. And we’re not completely ready. I am working in the epicenter at the busiest hospital—I think one of the busiest hospitals right now in New York City, with the greatest number of cases. As of last night, New York City had 6 percent of all cases of COVID-19 in the world. We are seeing on a daily basis the number of cases almost double.
If you walk out on the streets, the streets are pretty empty. Which is really great. I imagine if it was me walking on the streets I probably wouldn’t understand what all of the fuss is about. You hear a lot of sirens. They’re unending. You’ll likely hear quite a few during this call. Just nonstop patients are continuing to go into the hospital. You can’t feel that out on the street, at least not yet. But inside the doors of the hospital, as soon as you walk in, it’s very clear where we’re at.
I was giving an analogy, about a week ago all of us providers were kind of worried about, hey, who’s the—who’s the COVID patient? We have one or two people in each area that might be a coronavirus. Roll out, put on our PPE, we’re extra thoughtful and all a little scared. Now there’s maybe one or two people per shift that I see in the emergency department that is not coronavirus. It has taken over our emergency department. Yesterday within the span of three minutes we intubated or put on life support two people in rooms right next to each other. The majority of the people we’re seeing are old with comorbidities, with diabetes and high blood pressure. But a lot of the people we’re seeing are not. And it’s really important that we think about that message and how we share that with younger people, people who are otherwise healthy, people who think that this virus is not going to hit them. Because it will.
I think that there’s a couple of really important lessons that are coming from my experience and what I’m seeing on a daily basis. The big one right now that you’ve probably been hearing about is the PPE, the personal protective equipment. That’s the masks, the gloves, the gowns, the other things that we absolutely need to be protected—(background noise)—can you still hear me?
FASKIANOS: Yes, we can. I’m not sure what that was. But continue on.
SPENCER: OK. Sorry about that. Right. And so the most important thing that we need to think about right now is this PPE, this personal protective equipment. You’re probably hearing stories right now of providers in New York City and in other places that don’t have access to the gloves and the masks that we need to do our job. I can confirm that, unfortunately, that is true. Some of our best hospital systems and some of our number-one hospitals in the country are giving out one surgical mask a shift and one N95 respirator a week. N95 is that thicker, kind of more resilient mask, that helps filter out all those virus particles. And N95 is absolutely what we need when we intubate patients, when we’re doing anything that causes aerosol generation.
And so we’re reusing them. The CDC says don’t reuse your N95s, but a lot of my colleagues have no other choice. We need immediate action in our personal protective equipment. We can mobilize, you know, local supplies, research supplies. I’m getting emails on a daily basis from people who want to bring them from Wuhan or bring them from other places. Whatever we need to do, we need to be thinking about right now how we get more PPE. We can be doing that on a local level. We can be doing it at a state level. But I think the only what this is really going to happen is going to be at a federal level, where, you know, getting Hanes, and getting 3M, and Honeywell to increase their production is great but that is a drop in the bucket for the nearly 3.5 billion masks that we’re going to need if this pandemic continues into next year.
So we need to do this right now. And I think—I certainly would advocate for having a central supply of resource. This is something that Governor Cuomo has been calling for here in New York City—I’m sorry—here in New York. I think there’s been some pushback. This virus is going to slowly crawl across this country. We have some of the best hospital systems in the places that are most affected right now. In New York City I work at the number five hospital in the country. You see University of Washington in Seattle, a lot of places in California. But when this goes into areas where the number of hospital beds is lower than it is in cities, where the number of hospital staff is lower, the potential is unfortunately much, much, much, much greater. So I think that we need to have some concerted action throughout this country because it’s going to start here in New York, but it will—but it will be in Newark, it will be in New Mexico. It’s going to continue throughout this country.
The other thing that I think everyone’s been hearing about are ventilators. The reason that ventilators are so important is that for the majority of patients who have severe respiratory illness, this is the only option we have. We cannot put people on other modalities, noninvasive. So, like, things like masks—if anyone knows what a CPAP mask is. Sometimes we put people on those in the emergency room. We can’t do that here, because they’re too dangerous for the providers. They generate too much aerosol. And so we’re starting to intubate or put people on breathing machines much earlier than we normally would, because we know how this condition deteriorates pretty quickly. That’s great, but not if we don’t have enough ventilators. The estimated need in New York City alone is in the tens of thousands. And hospitals are already at the point where they’re double-venting patients, so splitting one ventilator in between two people. Our outbreak is hardly started, and this is the lengths that we’re having to go through right now.
So I think in terms of the state and local response, one, please just take this seriously. This will be in your state, in your communities in a week or two weeks, or four weeks. It will absolutely come. This virus is perfect in everything that it does. It doesn’t kill a lot. It kills enough to continue to spread. It spreads before people are really symptomatic. It is—it’s the archetype of the perfect transmissible virus, which is why it’s taking over the world. I think we need really, really strong local and regional coordination. We’re not going to get through this alone.
I know that there has been some initiative at the federal level, but I would ask every governor to make the same commitment that’s been made in a few places here on the East Coast to waive licensing requirements for all of your health care professionals, or to provide temporary licensing to make sure that when you, in Alabama, or when you in Idaho need providers, you’re not restricted by people that are only licensed in your state. We’re going to need people from New York that are convalescent, that have antibodies, that have this experience, to be going into different places, to help set up teams, to help respond. And that’s the only way that we’re going to get through this. I know in New York they’ve been sending out messages and been really heavily messaging on finding your retired health care providers and finding a way to bring them back in, get them licensed, get them up to speed. We’re going to need all hands on deck here really soon.
And then the other question that a lot of us have that we should be talking about with, you know, our local leaders and our universities, how do we use our health students? So those that are in nursing school, medical students, our public health students that are currently out of class or, you know, really not doing their research on other things that were keeping them busy beforehand. How do we find a way to keep them engaged, maybe in non-patient care activities, but in volunteer activities—helping with telehealth, helping with other initiatives that will help take the burden off of our emergency departments and ICUs? Because otherwise our system just will not hold. And that’s all I want to share. I’m looking forward to your questions.
FASKIANOS: Craig, thank you very much for that.
Vanessa Kerry, why don’t we go to you now to talk a little bit about the domestic and international challenges that we’re seeing COVID-19 having on our global health care system.
KERRY: So, first of all, thank you, everybody, for joining. I was very impressed to see the list and I’m very glad to know that states are concerned and are worrying about this. And I want to take a moment to kind of cover the COVID pandemic in three ways. One, kind of how did we get here—because I think people are sort of shocked with what has arrived. Secondly, how serious do we have to take this and what is the arc that we’re looking at going forward. And thirdly, how do we tackle this, and what does it look like, both for sort of our local and our international response? And where are there lessons learned from the international response to Ebola or to COVID that we could use?
I think it’s incredibly important to realize that when we see a pandemic happen of this scope and scale anywhere, whether it was looking back at China or now seeing it take over in some of our major urban centers in the United States, the key to preventing this as much as humanly possibly from being any more disruptive than it already has been or mitigating the degree of disruption is going to be preparedness. I can’t stress that enough. It is about what you do today and now that will change the course of this virus in your community and in your state. And it’s very difficult to want to pull a bunch of big triggers, I know, when you feel like, oh, well, it’s not here yet, or what if we don’t need to do this?
But I think to think that it’s—you know, I know that our president made a very interesting statement, if they don’t want the—he doesn’t want the cure to be worse than the virus itself. And I think it’s interesting because I can understand when we’re asking communities to social distance, and we’re asking businesses to close, and we’re asking the economy to take a big, deep, still pause, it’s terrifying. And that does feel very drastic. But if we do not implement some of these critical measures, we stand to have 60 to 70 percent of Americans infected with this virus. That is about, you know, 260 million people who could be infected. And if you put the case fatality rate and the number of folks who are at the high risk of doing poorly in this infection, that’s over one-point-three million deaths.
So for those of you that have states with older demographics, you need to think very seriously as well about what that is going to mean for your health care system, for your state, for your local economy on the—on the—you know, on the tail end. And so there are measures that we can put in place that will go a long way to—and I’m sure you’ve all heard this phrase of flattening the curve. No matter what we do, to speak to Dr. Spencer’s point, this virus is here in the United States. And we will be battling it for at least a year to a year and a half, to two years at this point. There is no way to speed up a vaccine. We have eleven fairly solid candidates in the pipeline right now, one that has already gone into phase two trials among humans. But to know that it is going to be safe and effective it’s still going to take at least a year to understand and make sure that there aren’t bad outcomes that happen from this vaccine.
So until we get a vaccine or enough or our population gets infected, dies, or gets immune to it—which is two years off—we are going to be having to address this. Now, that may make people feel like, well, you know, we just got to let it run its course then, because there’s nothing we can do. But the truth is, there is something we can do because what is playing out in New York City will be extraordinarily dangerous if it starts to hit cities in places where there’s only two ICU beds, or one local doctor, or there aren’t the kind of resources that we have in Boston or New York, where we’re—New York is completely already overwhelmed, as you just heard, and doing an extraordinary job of keeping up. And Boston is getting ready to be there shortly. And so I think that the most important thing I can say is that now that we’re starting to finally get tests that are coming up, I think that we have to be very strategic about what we implement.
Before I talk about some of the specific things that we implement, I want to stress one very important thing: The economic crisis in our states and our country will not end until the health crisis ends. There is no way for us to stave off an economic issue until we get control of what is happening from a health standpoint because we are going to constantly be reactive, and shutting down businesses, and people are going to be scared, and we’re going to be constantly playing catchup. If we take a very aggressive approach now and say we are going to do everything in our power to stop transmission, we will do far better to bite the bullet for a couple weeks, get control of the situation, and then be able to start to reopen our economies and be able to begin to start to think about what life can look like once we stop the chain of transmission.
But what’s happening right now is because we have not implemented social distancing around the country universally and in unison, we’re just getting a slow wave. So if Boston social distances but New Hampshire does not, then as soon as Boston relaxes its social distancing policies in three weeks and folks from New Hampshire come down to do business, and it’s still been transmitting in New Hampshire, Boston gets re-infected. Same thing if you think about, you know, Atlanta Georgia may be doing aggressive social distancing, but no one else in the greater Georgia state is doing that, then as business and commerce picks up again in three weeks, you’re going to, again, reignite the cycle of transmission.
Things that need to happen specifically at this point is we need to do a massive ramp-up of case finding. Testing is going to be critical to this. We have got to be willing to say: We are going to test everybody who has symptoms, and we are going to scale up testing and make it rapid, turn around in a matter of hours. In Massachusetts right now you have to wait five days for a test. That’s how backlogged we’ve been. We are finally getting online with faster testing, which is going to be critical to our ability to identify cases. Because what we know about the virus is that it acts in clusters—family clusters, community clusters. So if you can identify a case, you can start to trace the contacts and quickly identify who might be at risk for perpetuating transmission.
You are most infectious in the two to three days before you become symptomatic, which means if you’re doing your groceries, you’re going to bars, you’re visiting your elderly parents, you could be passing on the infection. We know three people will get infected for every single person who’s infected themselves. Anything we can do to disrupt the ability for three people to get infected from one is going to be very important. Contact tracing is going to be critically important. Additionally, if we know that cases are positive—this may feel very controversial, but this is why South Korea, China, and others were able to get on top of their infections—is if people are sick enough that they don’t need to be in the hospital, but can’t be at home for any number of reasons, opening your university dorms, opening hotels and other institutions to host those positive cases can help disrupt cycles of transmission.
Additionally, we really need to do everything we can to implement social distancing, and to do it all at once. And, again, if we just try to put those in places now, and everybody does it, we will disrupt that cycle of transmission enough that we will begin to relax social distancing a little bit as we get on top of sort of slowing the rate of people getting infected all at once. What does that look like? It means grocery stores can stay open, pharmacies can stay open, the post office stays open, hardware stores stay open, people who do electricity, you know, water works. Some of these core functions could all stay open. But you’re closing businesses. Close your restaurants, close—really trying to diminish the amount of kind of out and about access that people have. It will be very important.
And if we do that, again, for a few weeks, it will actually allow those businesses to open up again with far less risk, people far more trusting of their ability to go to a restaurant, to engage in these places, and will help reignite the economy. If you’re thinking of local stimulus packages and programs, you should be worried about the most vulnerable in your communities, I think, first. The first is, COVID is going to really exploit the inequities that we see in the country right now. People most at risk are hourly workers who don’t have access to benefits, don’t have paid sick leave. If they are sick and going into their community, then they are going to be infecting others.
But they may have no choice. They may need to do that because they’re worried about either feeding their family or because they’re required to go to work. So thinking about what it is to protect those works is going to be critically important. Your small businesses, your restaurants are all going to need the critical bailout packages as well that are going to be very important if we’re going to keep the economy going and running. And those are the folks that you should be thinking about.
Closing schools I know can be very difficult, because you have children, and these parents have to deal with what that looks like at home, if they’re working. I am working. My husband is working. We’re both trying to work full time. We’re both at home with both our children. And we’re trying to figure this out. But for me, to prevent the degree of death, destruction, and economic decline that is going to happen around this country if we don’t, it’s well worth it. But I think that by closing schools and by creating, again, some of these systems, it’s going to be important, but you are going to have to think about those children who get their meals at school. Who are the vulnerable families in your community that don’t have access to food otherwise, or for whom this is going to be deeply destabilizing? What are the kind of social structures or things that are needed?
Asking grocery stores to create hours that are seniors only that might help reduce traffic and make a safer environment, because what we do know is that COVID preferentially causes problems in folks who are sixty and over or who have cardiovascular disease, diabetes, hypertension, chronic pulmonary disease, cancer, or immunosuppression, including pregnancy, all have higher risk of doing poorly. And with each rising decade after the age of fifty you have a higher risk of death, so that by the time you’re over 80 if you are infected you have over a 15 percent risk of death.
The problem in this country is I think young people have heard this message that they’re immune or can’t get sick. And I think we’re seeing a very large and disproportionate number of infections in the twenty- to forty-year-olds now in America. And if you increase those overarching numbers, you are automatically going to start to see cases among that age group that do badly because the numbers are just—(inaudible). We have to communicate to everybody: This is a global—you know, this is a global response that we need to do, and it’s all of our responsibilities to join.
I think one of the most important things you can do from your state perspective is provide clear, concise information. Become the repository of accurate information to provide your public. It will calm people down. It will give them the resources they need. And it’s critically important to create, through all of the various channels of information, it is critically important to provide a source that people can trust and know is guiding them. It’s also critically important to provide the kind of courageous leadership and honestly that I think the American people need to hear right how that will go a long way towards calming people’s panic and allowing us to think strategically about how we recover some of the needs of this country, and some of the stability that we need.
Globally, COVID is an issue across the board. There is not a country in the world that is not vulnerable to COVID. And this is the extraordinary thing about this, is that we are all shared in this vulnerability, what this disease looks like. What’s been very remarkable to me now, a lot of the programming that I do in partnership with Seed Global Health, and the work that I do through the program in global public policy and social change, where we’ve very directly been looking at how do you protect vulnerable communities in health pandemics, and the importance of health to be central to economic growth, development, and stability.
And in all these programs, what I found is that the countries that are most vulnerable, actually, that aren’t arrogant about that vulnerability, have done an incredible job of quarantining, surveying cases, and really shutting the epidemic down. To give an example, Uganda’s just identified its first case of COVID forty-eight hours ago. And it did it through careful surveillance at the border. A plane flew in from the United Arab Emirates, and they screened every passenger who got off the airplane. One of the passengers had a fever. They tested him. They were able to get test results within three hours because they had already ahead of time scaled accurate, effective, and short-term testing.
They identified him, and they ended up quarantining this patient, as well as the entire plane, to keep it from coming into their country. They now have eight cases of COVID that actually were all on that airplane, but none other that they’ve identified in the country through careful screening and testing. And they know that because they don’t have a health system like ours that can remotely tolerate it. But I think it speaks to the importance of preparedness. It costs us less. It is more effective if we prevent this as much as we can, or the full effect of it, than if we were playing catchup with it after.
So I’m happy to answer questions. I really look forward to it. And I am really grateful for everybody’s time and concern, that you’re willing to be on this phone call. And I look forward to having a discussion. Thank you.
FASKIANOS: Thank you very much. Let’s open it up to the group for questions, best practices, et cetera.
Q: Our state has done a good job of preparing social distancing, even though people have not always adhered to it, but cases are continuing to spread. I get a lot of questions from my constituents of what can they do at home. I’ve even talked to some local doctors. I know it’s not our norm and our society to talk about home remedies, but in cases like this people are scared. They feel hopeless. Is there any general information, you know, zinc, garlic, ginger, anything like that that the CDC or somebody can help put out? I know we’ve never seen this virus before, and perhaps there is nothing.
But people feel like they want to protect their bodies. And just washing their hands is the only advice we’re giving people, and the staying apart. It doesn’t feel like enough, especially as people are continuing to come down with, at in the beginning, mild symptoms. And there is not enough testing here in the state of Illinois. The testing they have brought in is only for first responders by and large. Our hospitals are overflowing locally at the moment. So people do want to try to take care of their own health, but they’re given no information. And I understand that our system is very clinical, but is there something people can do?
KERRY: So I think it’s a terrific question. I think that it’s really important to stress to people that there are some—there are some—home remedies you have to be very careful with. So I think the number-one lede, I would say, is that people need to be careful with any suggested remedy or data that we think might help. So for example, it was suggested that there is an antimalarial drug, hydroxychloroquine, that may have an effect here. And people have gone out and gotten their hands on prescriptions and are now overdosing on it, and doing poorly. So the number-one for me is that everything needs to be done, you know, except for maybe handwashing, you know, with moderation, in the sense that you just want to be careful about not overdosing on anything you might be able to take.
And the reason I start with this is that there is a little bit of data that shows that zinc may actually help diminish the length of infection with the coronavirus or similar viruses by a day or two. And so there is—but I don’t want people overdosing, obviously, on zinc. You should take it as directed. But there is some indication that zinc may help. Additionally there is a study that came out that showed that people that take vitamin D supplementation, again as directed, not overdosed, may also help have lesser degree of pulmonary inflammation in the setting of coronaviruses. And so that may help mitigate any, you know, progression if you were to be at risk.
The most important thing people can do, probably, is reduce stress. Stress is a terribly insult to the immune system, as is lack of sleep. And I know it’s incredible impossible right now for people to feel unstressed, with what’s happening in the world. But the more that people can get sleep and try things like medicating—which I really think will be extraordinary. It’s worked in schools for kids who are high energy or don’t have focus, or—but I think that there are—there are practices—best practices we can do. I think what is also helpful is, again, handwashing. If you do go out and you have to go to the grocery store, I actually recommend when people come home they change their clothes and they wash the clothes that they wore to the grocery store, wash their hands. And that can be very helpful from a prevention standpoint as well.
Those are probably the top ones that I would advise at this point. And I think the one other thing that is critically important is that the WHO did issue a statement saying that there does seem to be some evidence that people who take Advil, ibuprofen, anti-inflammatories like Aleve, or NSAIDs of any sort may actually have an inclination to do worse if they get infected with COVID. So if people develop fevers, muscle aches, or any other concerns, they should take Tylenol or acetaminophen only. Acetaminophen is the generic name for Tylenol. And, Craig, I was going to say, do you want to add something?
FASKIANOS: Craig, do you want to add anything before we take the next question?
SPENCER: Sorry about that. I put myself on mute. Vanessa, I think your response was absolutely perfect. I think the one thing that we want to stress to people is, like Vanessa said, we don’t know exactly—there is no magical, there’s no cure-all. And we have to be really careful with how much we—you know, we put up purported remedies or promise too much. We know the best way to stop this virus is by not giving it a chance to spread. That’s why we’re doing the social or physical distancing. Washing your hands I know is boring, but it is really the best way to prevent this from spreading.
The one other thing that we often overlook is the importance of mental health. Anything that can be done, whether it’s, you know, downloading a meditation app or doing some video calls with friends and family, or just finding time to build a space every day where you’re committed to not talking about coronavirus, whether it’s five minutes or thirty minutes. A protected time that it doesn’t enter into anything that you’re doing I think is really important. Just finding mental health time, physical health time, you know, trying to do some exercise. There’s a bunch of online videos that are offering free trials for the moment. I think that those are really good ways to protect your physical and your mental health. And we have to be careful about promising too much for things that, unfortunately, will either have side effects or can make things worse.
FASKIANOS: Thank you. Next question.
Q: Good afternoon. Thanks for the teleconference. And I had heard that you’re looking for nursing, medical, or MPH personnel. So how would I go about or who would they contact to submit their names forward to help with this?
SPENCER: That’s a great question. I know that here in New York—that’s a really great question. I know at least here in New York there is a central resource, that you can go onto the New York State’s coronavirus website and put your information in, put your name forward. I think this is something that should be done everywhere. That’s going to be really, really important, is to get that surge capacity—you know, the people that have skills and that may be either out of work or out of classes right now. I’m not sure about how that’s working in other places. Vanessa you can chime in about up there. But in New York there’s definitely a central resource, and it’s been working really well. I’ve got a bunch of colleagues that have reached out and have been set up and ready to start contributing in the emergency department and other places.
KERRY: It’s a terrific question. I actually don’t know what we’re doing in Massachusetts yet, because we are not quite in the same position as New York. And so we have created a bunch of modeling around the hospitals that builds on existing staff. I do think that it’s worth reaching out to the Department of Public Health within your state to find out, but I also—I do think it’s important for every state, again in the preparedness, to start to build that roster now. Because when you need it, you will want it. And you’d much rather have, I think, somebody who’s a retired pulmonary care physician than a dermatologist doing intubations. And so you do want to think about what your health workforce is going to look like.
And we do know that one of the issues that is also coming up is that the health workforce is most at risk for getting infected—or, will become ultimately one of the highest risk groups to be infected through this. And then if you are infected, you have to—I think the question becomes, what do you do with them? And this is where some of the lessons learned from Ebola can actually be practical here. We finally have an antibody test. It just got developed, actually, by New York, NYU, that will—and what the antibody test tell you is whether or not you’ve been infected already. And this is really important too, because it will tell us not only if people have been infected, but it will tell us if people maintain their immunity to COVID.
And why that’ll be important is that if these—if health care workers have been infected and are immune to COVID, they can actually then ideally go work, you know, on the frontlines of this epidemic without infecting other people, because they built the immunity already. And so we have a few more questions to answer on this, but if this is true it’ll be very powerful to be able to put that workforce that’s immune in—back into work, because otherwise we—if we keep having to pull people out of the workforce because either they get sick—and, a couple of our colleagues who are in their forties right now are intubated in hospitals, who are health care workers and got infected. This is real, that we could lose health care workforce in this. You are going to have to think about who is going to fill in. And you want—and you want to make sure you have people who are qualified, trained, and I think really understand what they’re—what they’re dealing with.
Dr. Spencer raised a very important question, I thought. What do you do with your health care workers, like your students and others that may be laboratory techs, and people who have some scientific expertise but are not necessarily able to work? So in Massachusetts, we’ve shut down all of our research labs, unless it’s for COVID. And we did that in part because it social distanced everybody in the labs. We did it because we’ve actually needed all the reagent swabs and everything in the laboratories to be used to help create the testing system in Massachusetts.
So what we can do is, when you think about what it looks like to contract trace and identify who are the cases and the clusters in your community, and who might be at risk of developing it because they’ve been exposed, you can use those students and those folks that are furloughed from their day-to-day life to help be that community health worker, or the community health workforce to do your contract tracing, and to be able to help you do that under, you know, the support, if some epidemiologists can help you create that. But you have some built-in workforce that could be utilized, and people who are eager to help, that could help you scale up some of those efforts that are going to be needed to really shutdown the transmission of COVID.
FASKIANOS: Thank you. Next question. And I’m going to see if we can have just one of your answer, because we have over twenty-five questions in queue with fifteen minutes left, so—or twenty minutes. So let’s go to the next question.
Q: Thank you very much for all the info you’ve provided thus far. Quick question. I know that you said, you know, New York is being pretty much inundated. Massachusetts is getting ready for that. I think a lot of the uncertainty, at least in my state rep district, is are kids going to be able to go back to school the first week of April? When are businesses really going to—especially restaurants—going to be able to get back up and running? And I know that those models shift and change every day, but do you have any guidance on when possibly we’re looking at a little more normalcy when it comes to life and business?
KERRY: I’m happy to take a stab at this one. I think it really depends on how aggressive we are about social distancing and flattening the curve right now. At least in Massachusetts, understanding what the case trajectory looks like over the next week to two weeks is going to give us a much better sense of how effective we have been in breaking the transmission curve. I don’t think schools—and I think it’s very realistic through the first week of April, I suspect even the second week of April. I do think for the state Massachusetts the curve—we will be better able to answer what the post-mid-April looks like once we have a little bit more data in the next couple weeks. We are not going to go back to normal, though, for a while—totally normal. We are going to have to be cautious and thoughtful no matter what because, again, this is going to be circulating in our community and in our country at a significant amount for the next year and a half to two years, until a vaccine comes on board and we really—or enough people get infected.
And so I think that we are going to have to be—I think this is going to be a little bit day by day right now. And I think that if we can be honest with folks about that uncertainty, it actually will let people embrace it more than creating an expectation that we break again in the future. And I think that if all states, again, buckle down on this together, because people are still going to cross state lines and make movement, the more we do this together all at once, and really create a complete effort as a country over the next two to three weeks, the faster we’re going to be able to get ourselves back to some semblance of normal, to commerce, to business, to restaurants opening, to schools going back.
But if we—you know, excuse my expression—half-ass it right now, we’re just going to be dragging our feet towards an inevitable point that we’re going to have to do. And so there’s—and we know that—from, like, the 1918 pandemic flu, that when Philadelphia kept its parade, it—I can’t remember now if Philadelphia kept it or cancelled it—but one city kept it and once city cancelled, and the difference in cases was, you know, a hundredfold, just with forty-eight hours difference of when social distancing was implemented.
And so I think that we have to kind of just dig in, lean into this—(inaudible)—put all the stopgap measures that have to be put into place at once, and then I think take that next two weeks of time to see where we end up, and then start to plan. I know it’s not the answer people want to hear, but I think if we embrace there’s a level of uncertainty through the next couple weeks. And I think the more dense your population and the less social distancing you’re seeing among your communities, you should anticipate that you’re going to be in it for longer.
FASKIANOS: Next question.
Q: We know that there’s a shortage of the N95 masks. We’re facing that here in Georgia too. So if—my question is, to extend the life of those masks, if the provider was to put one of the, you know, paper surgical masks or a 100 percent cotton, you know, washable mask over the N95, would that be an effective method of extending the life of the N95, if the cover mask was replaced regularly?
FASKIANOS: Craig, why don’t you take that?
SPENCER: Absolutely. Very happy to. Thank you. That’s a good question. And that’s exactly what people are being advised. That is certainly a stopgap, but it’s not ideal. What I’ve noticed, as someone—I’ve worked in West Africa during Ebola. Very strict adherence to PPE was the most important thing to prevent you from becoming infected. Only good use of PPE is helpful. PPE, personal protective equipment, by itself is not helpful. Only how we use it. So my concern with assigning kind of other measures, like, you know, putting a surgical mask outside of an N95 mask, is that there needs to be really clear guidance to your health care staff on how to use that and how to do that well. So that means removing the mask—the outside mask—correctly, changing that after any visible soiling, and this may extend the life of the N95.
The problem with the N95s is that the CDC does not recommend that they’re reused. The longer that they’re used, you can get more liquid from breathing, they can get wetter, then they’re just less effective. So the ideal scenario would be to be reusing—or, to be using an N95 with different patients, and using it well. We know that it’s going to be impossible to have a separate N95 for every patient encounter, with the number of patient encounters we’re going to have. If we need to extend, the use of the surgical mask outside the N95 is OK, but it’s certainly not ideal.
Q: Hi. Good afternoon. Thank you so much for taking the time to give us all this information. I have kind of a few questions. The first one was you mentioned the need for ventilators. At the state level, we’re trying to figure out the best way to procure funds for all the hospitals in New York state. But I was wondering, is there even enough of ventilators available to procure? And where is the biggest need? Is it to, you know, health centers or big hospitals?
And then the second question I had was, so the Department of Health is following the state guidelines for reducing the nonessential workforce by 100 percent, obviously. But the nonessential part I think—I believe it’s still to this day under—you know, it’s up to the employer’s discretion. And there are still some cases of workers—and we were on some calls from constituents—that they’re still being—they don’t present any symptoms, they haven’t been necessarily very close with anyone who was infected, but they’re still being sent to facilities or big classrooms, and things like that, and they could be at risk.
So I was wondering if there’s a way to kind of release a statement either statewide or, you know, throughout the country that, you know, some health providers or—that emphasizes the importance of cautionary quarantine, and making sure that workers—or, employers who have—who still keep the nonessential up to their discretion are—really truly understand that, you know, it’s better to kind of, like, keep as many of the workforce at home, as far as is possible?
FASKIANOS: Thank you. Who wants to take that?
KERRY: I mean, I’m happy to approach some of it. Do you want to do the ventilator part, Craig? Or either?
SPENCER: Yeah. Yeah.
KERRY: Go for it.
SPENCER: I’ll start with the ventilator part. Thanks for that question. Yes, ventilators are everything that we need right now. As I mentioned earlier, we’re putting people on ventilators earlier because the other options we have are not ideal right now. We’re also seeing people who decompensate—so who get stick really quickly. They do it really quickly, and they need a ventilator. They need to take over—we need to take over their respiration. The ventilator is the best chance for anyone that has respiratory difficulties. Without them, we just can’t put people on them.
Like I said earlier, there’s not a magic drug or anything that we can give people to get them better. We literally just have to take over their breathing for a couple days, or longer. There has been a push, obviously, to opening up the huge Javits Convention Center here in Manhattan and taking over a couple schools. I think what we’re going to need to do is we’re going to need to have these kind of really big field hospitals, where we’re able to keep people ventilated for a few days to the point where we can, you know, take out those breathing tubes, hopefully, and let them convalesce. But yeah, if we have enough ventilators, I think we can do this. But without them, it’s going to be really difficult.
KERRY: I think then the question of who is a nonessential worker, I actually think that the state should create that guidance. I think that this is where clarity of information and leadership is going to be really important, because I just spoke to a couple of my colleagues in California, who I found out were still going into the office. These are nonmedical colleagues. And I asked them—I said, why are you still going into the office? And they’re like, well, they’re still doing court cases, and so we have to prep our cases. All our files are in the office. And I’m sitting there thinking: You know, this is a time of national emergency. And unless—and I think that, you know, to do worker—you know, whatever the various court cases are, you know, eviction cases or things like that, there are certain things that I think for now need to wait a couple weeks while we get on top of this. And I think the direction is going to be really important.
And this is—this is going to be a bit of an existential, you know, struggle, I think, for this country, as we—as we’ve always battled with what is sort of, you know, government versus individual rights. And I think it’s a really hard—you know, I want to really recognize that we have a lot of individualism and a lot of different tolerance for what that might look like in different locations. And I do respect that. I think, though, that we are really talking about a national emergency that is going to threaten the lives of the hundreds of millions in this country, and of your constituents. And the reality is that we are going to be irrevocably changed by what we are going through for now.
And our legacy is going to be determined by how we respond. And we can either respond slowly and a lot of people get sick, and a lot of people die, and the economy gets it even harder than it can. But if we respond with clarity, honestly, and guidance to our population about what needs to happen for a couple weeks in order to get control of this pandemic in this country and stop it from really causing even more damage than it already has. And so I would encourage you if you have that ability in your state to set the guidelines of what you consider essential or nonessential. And I think you’ll find that people are scared and will adhere. But I think it’s really important to think about where there’s opportunities to postpone thing—court cases, things like that—that can help the whole system, you know, kind of back off for a little bit.
FASKIANOS: Thank you. Next question.
Q: Thank you. I appreciate all of this information. My boss represents southern Brooklyn. We have a large population of elderly people, people who are homebound. And we’re kind of dividing the job into three categories, addressing immediate needs, getting people food, making sure they stay inside; figuring out how to organize or restructure the economy in light of this; and the third thing—which is my question—is safeguarding basically the institutions of democracy. So I’ve heard from a number of constituents who are going stir crazy and wondering what they could do to help.
So we have mutual aid networks. I’ve encouraged people to participate in the census and reach out through social media to, you know, their contacts. And we are trying to do an aggressive census canvass in the middle of a pandemic, which has never been done before. And so I was wondering about how we do that and how we can conduct safe elections come November.
FASKIANOS: I think we have to organize another call specifically on that topic. (Laughs.)
KERRY: Yeah, I think it’s—it’s a huge one. It’s so important.
FASKIANOS: Yeah. And it might be outside of—
SPENCER: Can I make one—oh sorry.
FASKIANOS: No, go ahead. Go ahead, Craig. Yes, please.
SPENCER: No, I just—I really just wanted to make one quick point about the first thing you mentioned, which was the elderly population. Right now our marginalized populations are even more marginalized. Every single day in the emergency room I get an elderly woman who was sent in for testing because her home health aide tested positive. And even if she tests negative, no one is willing to take her home, so we have to admit her to the hospital. Asymptomatic, nothing else going on, we just can’t either send her back home or send people back to nursing homes because right now things are kind of in flux and we don’t know what the risk is of sending a coronavirus patient back to their home with a health aide who may be convalescent. And there’s not a lot of places to send people who are coronavirus positive but don’t need to be in the hospital.
We’re figuring that out right now. But that’s something that you all should be thinking about, I think, very, very soon. The other thing that I think is really important is that there’s an excellent resource that I think was just posted up today or yesterday by an amazing team of people I trust a lot, from the Center of Global Health Science and Security, from Center for Global Development, from NTI. It is a decision—it’s a frontline guide for local decisionmakers—so basically everyone on this call. It is a checklist of the things that we need to be doing in our communities, how we slow and reduce transmission, how we do risk communication and community engagement, mitigating the economic and social consequences. It’s really fantastic. And it’s at COVIDLocal.org. So, C-O-V-I-D-L-O-C-A-L dot org. I think that’s a key resource for anyone kind of working locally or regionally, in the absence of any really strong federal direction on some of the issues that you’re going to be facing.
FASKIANOS: Thank you. Next question.
Q: Thank you very much. I am the deputy mayor in Burien, Washington. We are a city just outside of Sea-Tac Airport, just south of Seattle, Washington. So you can imagine what our community is going through right now in terms of this epidemic and pandemic. I also sit on the board of health in King County that governs thirty-nine cities throughout Washington State.
My question is in regarding—or, is in regards to preemption and what local leaders can do that is not already being preempted at the state level. As you know, we are able to set a lot of policy laws around health care or sheltering in place that are outside of state authorities. So looking for recommendations on what we can do there, and how you can recommend us best working with many—you mentioned college dorm rooms that could potentially be used to house people that have tested positive for COVID-19. Any of the recommendations that you have for local elected leaders who may be prevented from a state level.
KERRY: I think it’s a terrific question, and certainly, you know, the various hierarchies play out, you know, all the time here. And it’s—I think that, again, what is very important, and local leaders can do a terrific job of doing this, is to think about your individual community and how do you get accurate information they can trust about social distancing, about how to prevent, you know, infection, about kind of the social responsibility here to help break the cycle of transmission. You know, where they can maybe make donations, or focus their energy, or provide support to the community.
But I think because there is such a diversity of communities, you know, in your individual community you might have a particular cultural bend, or an older population, or you may have a particular cultural—you know, a culture, or population, or a language barrier, or things like that. Being able to make information accessible, culturally relevant, and understandable will go a long way to helping this because, even if there’s not a shelter in place, if I could tell every twenty-year-old to get away from another twenty-year-old and just quietly stay home and make it work for two weeks, and actually get that message across in an effective way, I will have done a tremendous job—or, we will have done a tremendous job—of helping to disrupt what’s happening in terms of transmitting.
The way this virus loves going human to human, very, very effective at it, as Dr. Spencer mentioned at the beginning. And I think that if we can disrupt that piece of it, it can’t get the same kind of toehold. And so that’s the power of local government, is to really think about what are the initiatives and ways that you can engage your local community to make this information available. And I think—for example, I just did a conference call with social influencers in our community, which I don’t remotely think I have anything in common with. But I can provide them with the really important factual information that they’re now pumping out to twenty-year-olds through videos, through all the various chat channels and things, to try to change this cycle of communication, because that’s the way that twenty-year-olds communicate. So if we can—if we can think about what are the strategic ways to get the right information out, I think that’s important.
I would also—and I know you guys have been incredibly under fire in Washington state—if there’s ways to create a taskforce in partnership with the government to help think about how do you organize, you know, all the local chairs together, and the local communities together to do what you can do, even in—you know, within the parameters of what your flexibilities are, you can do best practices, lessons learned, and you can probably help scale across the whole state effectively. I don’t know if that’s helpful, but those are my initial thoughts.
FASKIANOS: I would like to try to squeeze in one last question. And I apologize for not getting to more of your questions.
Q: Hi. My question is basically—we’re in Virginia. And our schools are already closed for the rest of the school year, meaning I have hundreds of young people at home, plus many college students, because most of our colleges have closed and gone to online only learning. And we’re from such a rural area where half of our residents don’t have internet services. So we’re trying to find any way that we can make—how can I help these people? Because that’s the biggest concern. Also, the lack of testing in our area. What can we do, or what can I tell constituents about, you know, what—how we can help them in this situation?
FASKIANOS: That is another good question.
KERRY: It’s a huge one. And this is the big issue. And this is the place where I think—just to take—I think you need to actually have another call on this one specifically, because I think what it means to scale up services to rural, inner city, and communities that don’t have access to internet or to the tools you need to do online learning, like computers or, you know, iBooks and iPads and things like that, is going to be a real issue. But I think that needs to be tackled very much.
I would encourage you to call your local businesses, your consumers. I don’t know what you have in Virginia, but RCN, whatever your cable providers are, your internet providers, and ask them to help make this contribution. It’s going to be good business for them, because people are going to, you know, get access to the internet that maybe eventually when the economy recovers they could start paying for separately. It increases the visibility and the CSR of this moment if they’re able to provide those resources. But I think you could put some pressure on businesses to give in this moment, and to do their collective part. And I think also the state’s going to have to come up with a pretty big strategy.
The other way to do it is to potentially film classes that could get broadcast on local TV. So at least if people have TV, and people could all gather for class at 2:00, or create a network channel where teachers broadcast into houses at certain times, and certain classes, is better than nothing. But I think this is going to be one of the great challenges, is how do we protect our most vulnerable in this moment? And I think that also stimulus packages that we create should go directly into the hands of families that don’t have access to resources so that they can get the resources they need to protect themselves, their children, in this moment. It should not necessarily be going, you know, to big businesses and things like that. It needs to go to the people who are the end users, and the folks who really can’t be left behind in this moment.
FASKIANOS: I’m going to take a couple more questions, I think. If both of you can stay one for another five minutes, that would be great.
Q: Hi. We’ve had a number of—small number, thankfully, of cases. And obviously we’ve instituted practices related to social distancing and actually have limited access to our facilities. One of the questions that’s come out from the community is whether or not there is any efficacy behind developing homemade, if you will, masks. And I certainly don’t want to promote any type of false sense of security. We’ve pushed social distancing as the number-one option. But people are continuing to ask us about whether or not use of masks would be appropriate when they have to enter the supermarket, or the like. So any insight would be very helpful.
FASKIANOS: Craig, do you want to take that?
SPENCER: I’m really happy to—yeah, I’m happy to take that question. Thank you. It’s a little tough, because the messaging around masks has been confusing, I understand, for a lot of people. There’s certainly—you know, you look at any of the pictures from China, and every single person was in a mask. I think there’s definitely a different culture around mask use in many parts of Asia than here in the United States. One thing that I think is really important is making sure people who have—who have comorbidities, who have immune issues, who are transplant patients, who absolutely need masks should have access to them, if there’s a way to do so. Hopefully those patients are able—I’m sorry—those people are able to stay home and to, you know, practice social distancing as much as possible.
I think it’s a challenge for many people to say whether we should be recommending masks for everyone when they go out, as opposed to continuing to say: Please just don’t go out. Please socially distance, because the virus can’t find you if you are not out. If it can’t catch you, it can’t make you sick. So it’s a little difficult in terms of how we do that messaging. We don’t—as you said, we don’t want to give people that false sense of security if they’re wearing a mask, because what I find most of the time is that most people—especially, you know, non-health care professionals—are not wearing a mask correctly. They’ll have it over their mount, but not over their nose. They’ll touch things, they’ll touch the mask. And most people don’t understand that it can actually be a—it can increase your risk of infection if you’re not using it well.
The messaging around whether people should be wearing a mask or not, I think there are communities or groups of people that should absolutely if they need to be out for any reason, people that have underlying illnesses for example. But for the majority of people, I think having them get masks, having a rush on masks, just means less are available to our health care providers. And we should continue to really instill this message of social and physical distancing as the best way to protect everyone, as well as our health care providers.
Q: I have a question in regards to demographic information. It seems that a lot of people are stating that we don’t really have those numbers yet from the CDC, as far as do we see any trends. Is the virus affecting certain populations or certain areas, or certain economic backgrounds more than others? Do we have any information that the CDC has released yet about demographics and the virus?
KERRY: Specific to the U.S., I’m assuming?
Q: Yes. Correct.
KERRY: Craig, do you want to do this, or do you want me to start?
SPENCER: Please do.
KERRY: So I mean, I think that this has been rapidly, rapidly evolving. And we do have some sense of what on a more anecdotal level, than we do sort of necessarily in fully released journal articles that have been peer reviewed and released fully assess what the epidemic looks like. I think that based off the statistics that we do know, the trends in the United States for the most part follow the global trends that we have seen, which is that of the deaths in the United States, the vast majority have been among those over the age of fifty, with a higher group in—you know, getting higher with each rising decade.
I think as of about two weeks ago, over 44 percent of the deaths in the country were in a population over eighty. And so we are focusing on this trend that you’re much more vulnerable of you’re older. And certainly the deaths have been driven by—were initially driven by, back in January and early February—by the fact that COVID had affected a nursing home.
That is changing now. We are seeing deaths from—again, mostly over fifty—but we are seeing folks younger, who are in their twenties, and thirties, and forties, who have been intubation and are requiring critical care now. And so even though the—and folks who are dying most likely do have some kind of comorbidity or other issue that is driving the fact that they end up dying. But everybody is vulnerable in this. And everybody is possible that they could require critical care, and have, you know, outcomes from that, need a fair amount of rehabilitation or support afterwards. And we’re seeing that in all age groups.
About half the people now who are in ICUs are actually within the age of twenty to forty now, even. And that’s in part because I think the infection is rampant among young people as they’re going out, not social distancing, and thinking they’re immune. So we are seeing—maybe it’s not 50 percent. Craig, you may need to correct me on that because I’m sleep deprived and not fully remembering the statistics. But it is a significant percentage that I want to flag of young people now who are requiring critical care. And so the key to this is the most vulnerable for dying remain over the age of sixty. We do know that children under the age of eighteen do not seem to be very effected by it. And that probably reflects cross immunity from other coronaviruses and things that they’ve been exposed to, but we don’t really know right now.
We do know that people ages twenty to forty remain vulnerable and can require critical care and do poorly. So we—but it’s following the data that we know coming out of Europe and following the data that is coming out—that came out of China, and South Korea, and Japan.
Craig, please do add on, because I don’t want to misspeak on this incredibly important question.
SPENCER: No, I think you captured it pretty well. You know, the data that we’re seeing versus South Korea, versus Japan, versus China is all a little bit different. But what we are consistently seeing is that young people are impacted. A lot of the sickest people I have seen have been in their thirties. We know that apparently we’re seeing some of this data as well, women seem to be—you know, get the infection more, but men are more likely to die. But it’s really across all ages. I know at least up until a couple days ago here in New York state the majority of our patients, over 50 percent—I think it was 54 percent—were between eighteen and forty-nine years of age.
So this is another really important thing on the messaging that I think we can be taking back to our local communities, is that it’s not just the elderly people. And we talked about this early on. Stay inside to protect the elderly, to protect the vulnerable. It’s not just the elderly. We have—I think here in New York City we have a teenager that is on a ventilator with no medical history. The likelihood if you get it and you’re young is that you’re going to be perfectly fine, but it’s certainly no guarantee.
FASKIANOS: Well, thank you both very much, Dr. Vanessa Kerry and Dr. Craig Spencer, for being with us today, for your insight, and for all the work that you’re doing in the ER on the frontlines. We appreciate it. And to all of you, who we know are trying to reassure your communities. And I think the biggest takeaway is clarity, honestly, and guidance to your communities is so important.
We will continue to convene these calls. You’ve given us some ideas on other topics—what we need to focus on, elections, you know, lack of resources in rural communities. And we’ll get to work on standing up calls on those, as well as regular updates on COVID-19. You can follow Vanessa Kerry on Twitter at @VBKerry. You can follow Craig Spencer on Twitter at @Craig_A_Spencer. So please do so. Also, on the CFR website, CFR.org, we have numerous resources, free resources, on COVID-19, other conference calls. You can listen to the audio, read the transcript. And we will continue to stand up these calls. So thank you all. If you have specific questions or other ideas of what we can cover, please email [email protected]. So thank you all and stay well.