Category: Culture

Five pandemic predictions five months later. Was I right?

published date
September 21st, 2020 by
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Looking back

In April, with the pandemic raging, lockdowns underway in the Northeast and West, and widespread panic about what the immediate future would bring, I tried to look over the horizon to see where we were heading. My 4 predictions for the next phase of the COVID-19 pandemic and Prediction 5: The end of immigration, distilled what I was seeing in Boston plus what I was hearing from healthcare and life sciences clients and physician and scientist friends in US hotspots and around the world. I didn’t put a timeframe on when this “next phase” would be, but with the summer behind us and a new school year getting going, now seems like a good time to take stock.

Judge for yourself, but overall I think I did well. Let’s review:

#1: Treatment, not testing will be key to reopening the economy
Grade: B

I was right that testing wouldn’t be our savior, but also overestimated how quickly treatment would improve.

In April, everyone was talking about the need for millions of rapid turnaround tests to get things moving again. Other countries, like Germany and Singapore had deployed testing on a massive scale. But when I looked at what was going on in the US I was unimpressed. There were lots of announcements about capacity but little follow through.

Sadly, we’re still doing poorly. Recent estimates suggest the need for 193 million tests per day; we’re only doing 21 million. In Massachusetts (one of the leaders in testing) it’s still hard to get a test if you’re not symptomatic. Test results elsewhere can take a week or even longer, if you can get tested at all. Bill Gates recently criticized the current state of US testing: too few, too slow to return results, wrong swabs.

The absence of rapid turnaround testing at scale and weak contact tracking has hampered the ability of scientists to inform policy makers and the public about what works and what doesn’t. This failure contributed to the rapid spread of disease in early hot spots. It also fed public confusion and undermined support for guidelines, which seemed vague, random and contradictory.

Remdesivir was already showing promise in April, and non-drug adjustments such as optimization of mechanical ventilation and turning patients on their sides were being tried. Intriguing stories of cardiovascular impacts and cytokine storms were emerging. I expected we’d have a bunch of drugs and other innovations that would make COVID-19 a manageable disease by now. The death rate is down, but treatment improvements have been incremental and some early hopes fizzled. Dexamethasone, an old steroid is the only drug beyond remdesivir with widespread evidence of effectiveness.

There are new possibilities ahead. Olumiant (baricitinib) appears to help patients on remdesivir recover faster and may gain emergency approval by the time you read this. And researchers are looking at new mechanisms, such as bradykinin storms to understand how COVID-19 does its damage and how to stop it. There are several other treatments under evaluation, too.

Bottom line: fatigue, denial and surrender were bigger factors in reopening decisions than I expected. The economy still isn’t fully reopened and we may need to wait for a vaccine to move back toward normalcy.

#2: Hybridization (virtual/in-person mix) will be the new reality
Grade: A+

I’m proud of this prediction. At the time I made it, the consensus was that everyone would return to the office by summer and get back to school in September. That hasn’t happened. Instead, as spaces reopen, hybrid models are emerging everywhere to reduce density and decrease risk. You see it with schools, businesses, physician offices and clinical trials. Remote work and school are still happening, but work from home is no panacea.

I expect hybridization to outlive the pandemic as individuals and organizations learn that a mix of in-person and remote is best for most activities. But patients may have to assert themselves to receive the full benefits of hybrid care, because healthcare organizations have a tendency to revert to what works for them rather than what’s most convenient and affordable for patients. Telehealth was used for almost 70 percent of total visits in April before dropping to around 20 percent in the summer. Some patient-centric leaders, such as Boston Children’s Hospital have maintained rates at close to 50 percent.

#3: Public health post-COVID-19 will be like security post-9/11
Grade: B

When I started traveling again soon after 9/11, the sudden jump in security at airports, office buildings and public spaces was staggering. In the following months and years, security became a huge industry and an obsession.

In April, I wrote:

“Now that COVID-19 has struck, we can expect public health to be similarly elevated. It will become a pervasive part of our economy and society. Expect temperature –and maybe face mask and hand washing– checks at the office, school, and any public venue.  Contact tracers may call or visit our homes or scrutinize our cellphone records. Event managers and employers will need to hire a health team and devise a health/safety plan to prevent outbreaks and provide confidence.”

I’ve certainly seen this in the private sector. For example, many private schools require daily health attestations, temperature checks, masks, outdoor eating, etc. Stores announce, “no mask, no service” policies in their windows. Some states and counties have good contact tracing programs, but unlike 9/11 there is no nationwide approach, and no Homeland Security equivalent.

As more venues reopen I expect that this trend will continue. What’s not yet clear is whether public health will receive additional funding and just how central it will be to our future. Much depends on how quickly and completely the current pandemic is brought under control, whether new health threats emerge soon, and who occupies the White House in 2021.

#4: Federal government will grow even more powerful relative to everything else
Grade: A-

This prediction was paradoxical. Those I reviewed it with at the time found it novel and counter-intuitive. After all, the feds failed to prepare for the pandemic and threw everything onto the states. The CDC embarrassed itself with its testing approach and then was sidelined.

But the federal government has essentially unlimited spending power, which it used to prop up the economy with the $2+ Trillion CARES Act, and the stock market (via the Federal Reserve). Meanwhile, states had to come begging –quite literally—to the president for help, and our world-leading universities and colleges found themselves in desperate straits and unable to reopen.

In short, the federal government’s failures have weakened the rest of US society much more than the federal government itself has been weakened.

The reason I give myself an A- instead of an A is that I didn’t address what would happen relative to the rest of the world. The US federal government has lost international standing during the pandemic with its poor response. The country was rated as the most prepared for a pandemic –but botched things anyway. The withdrawal from the WHO weakened our hand, and our slow economic recovery means we’re losing ground on China and others.

#5: The end of immigration
Grade: A

Crises present major opportunities for governments to enact policies they wouldn’t be able to get away with in normal times. The current Administration has made no secret of its disdain for immigration.  It had taken some dramatic steps before the pandemic, such as curtailing the H1-B program for highly skilled workers and attempting to build a wall along the Mexican border.

In April, the president tweeted his intention to suspend all immigration. That’s about as dramatic as it gets and would have drawn much more fire even a month or two earlier. But with lockdowns and travel bans throughout the world, and a virus floating in the air, it was harder to argue against. Consider some of the additional actions taken against immigration during the pandemic, including bans on asylum seekers and refugee resettlement, a ban on international students coming to the US if their classes were not in person (rescinded after pushback), and more restrictions on H-1B lottery winners.

The pandemic has also made the US a less attractive destination for would-be immigrants, even without all of the explicit actions. That won’t be reversed quickly.

What’s next?

There are big questions for the next few months and years, including:

  • When will vaccination make a decisive difference? This includes when vaccines are approved, how quickly and rationally they are distributed, how well they work and for how long, and what the uptake is.
  • What will the economy of the early 2020s look like? Will travel and leisure return? Education at all levels? Office work? What new industries will emerge?
  • What will be the US’s role in the world? Much of this hinges on the results of the 2020 election and its aftermath.

I’ll offer my commentary on these topics as the situation continues to unfold. Check the Health Business Blog and HealthBiz podcast for updates.

In recent months, my strategy consulting firm, Health Business Group has helped our healthcare and life sciences clients factor the implications of the pandemic into their growth and M&A strategies. Would you like to discuss your own organization’s plans and how Health Business Group can help? If so, please email me: dwilliams@healthbusinessgroup.com.

COVID-19 contact tracing. The 7 keys to success

published date
August 14th, 2020 by

This is a guest post by summer intern, Marina Zapesochny.

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Mask wearing, social distancing and testing are helping bend the COVID curve in the US.  Increasingly, local communities and states are adding contact tracing –one of the oldest tools in epidemiology– to break the back of the outbreak. Contact tracing is highly effective for limiting COVID-19, but only if done well. Here are the 7 tips for getting it right.

  1. Recruit “people persons” as contact tracers

Contact tracers need to have difficult conversations with people all day long. Training helps, but too often the focus is on the technical aspects of the job.

The real emphasis should be on hiring people with the right personalities. That means “people persons.” You know, the folks who like to strike up conversations with strangers at the supermarket or bus stop and ask all sorts of questions about personal matters.

People persons will have a much easier time talking to others than those that lack those skills. CDC training instructions for contact tracers focus only on how to get in touch with people, and how to trace who they have been in contact with. Nowhere does it address how to schmooze with people, how to build trust with them or how to really empathize with them.

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  1. Follow the “Paterson Principle” by building trust at the community level

Building trust is essential in a community where contact tracing is implemented to protect public health while also respecting people’s privacy. People can’t feel stigmatized when they are called about COVID. Spreading awareness that a contact tracer might reach out, and normalizing it by communicating about the program in local forums can make people feel less targeted.

Paterson, NJ is handling contact tracing particularly well. It is the second most densely populated place in the US after New York City. As soon as the pandemic began, Paterson expanded its contact tracing team in preparation. The mayor, Andre Sayegh had the coronavirus and beat it. Following his recovery, he said “I survived coronavirus and so will Paterson.” The mayor himself was contact traced and strongly endorsed the program. The mayor was prepared and open with his citizens. If more cities treated contact tracing this way, trust would grow.

Who answers calls from unknown numbers? With so many spam calls nowadays, most people don’t. That makes it extra tough for tracers. Portland, OR  is one of many places struggling with this challenge. People don’t answer the phone and only about one in five are willing to share their contacts.

If local media explained contact tracing  better and let people know what to expect and why,  people would be less hesitant to pick up and cooperate. Building trust in contact tracers and the security of it in a community is what produces the best results

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  1. Remember: Less is more

Contact tracing only works when cases are rare. The US was caught flat footed in early 2020 with a lack of testing capacity and federal leadership; cases exploded and contact tracing was no longer practical. Now that cases are declining in some parts of the US, contact tracers can be reasonably expected to find all the people the infected few were in contact with and warn them relatively quickly of their exposure. But the only way to get to a low number of cases is for the whole community to take  precautions such as social distancing and wearing masks. This makes it possible for contact tracers to do their work. The tracers can then accelerate a virtuous cycle to crush the curve.

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  1. Help COVID apps go viral

Several companies have created apps to assist in contact tracing. However, almost no one is using them. A good way to improve the quality of contact tracing would be to make these apps more mainstream and attractive to users –in other words, help them go viral.

The potential for many of these apps is amazing. If enough people used them the apps could provide alerts when a COVID-positive individual is nearby. But unfortunately, such apps need at least 60% of the population to use them. So, the questions stands, how do you get people to want to download the app? According to Harvard Business Review, the best way to get people to actually use the apps is to follow the Facebook and Uber models: start in a small area, expand it one city at a time and then launch globally.

The current approach to having people download these apps depends on the country. In China it is mandatory and in Iceland in is voluntary, but newsflash, neither is generating enough use of their app!. The Uber/Facebook model sets an exmple for the use of these apps. One of the apps with potential is Contact Tracing by Piusworks LLC. It is a free app with easy to understand instructions. However, the reviews on the Apple App Store lean to the negative side with many of them saying it was “not ready for release.” This is because they released to the general public all at once instead of following the Uber/Facebook approach. If they rebranded and relaunched to just one city at a time the results and reviews would be much more positive.

Uber, itself has played a part in sharing contact tracing information. Uber started sharing information with health departments on both passengers and drivers. The health departments can then track who used Uber services and encourage them to get tested and quarantine. Privacy remains an issue. Such a big company sharing the information of others seems like a violation, but it is covered in the Uber user agreement.

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  1. Keep up the good work!

One call is not enough. It is necessary to follow up with people to get their contacts and sometimes to connect them with support resources. This was especially relevant during the AIDS epidemic. These practices are helpful, but more could be done. Contact tracers should check in with patients, not just for information but also to have a conversation about how the person is doing over time. Even a short conversation goes a long way.

Patients should also be checked on to make sure that they are getting the care that they need (are they in the hospital? did they get tested? are they quarantining?). These steps will reduce the doubt that the public may have had in contact tracers before. But the contact tracers can’t do it all. Partnering with other organizations so that people could get their support quickly and easily would be a fantastic idea for contact tracers. Local organizations already have connections and a reputation in the community. They could help contact tracing organizations develop a reputation with the community as well.

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  1. Leverage the data, lose the bias

Analyzing patterns in the population of infected individuals can yield helpful insights. If people of a certain neighborhood, religious group, ethnic group, etc. are getting COVID more often, that can guide allocation of resources for intervention. Perhaps some people from a certain neighborhood are continuing to get together despite social distancing guidelines, or a religious organization isn’t requiring facial coverings. The important thing to remember when looking into this is to not input any bias or stereotypes, but let the data do all the talking. Singling out groups is a very taboo subject, but finding patterns and using them well can be effective. Another important part of it is making sure that people don’t feel targeted. Targeting people rather than just discussing patterns with them is harmful, because they won’t trust contact tracing anymore. Finding patterns, investigating them, and then informing the groups that are continuing to get sick could greatly reduce the amount of COVID positive cases. It also helps to warn members of those groups that they had a possibility of exposure before they even show symptoms.

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  1. Testing, testing, 1-2-3

Quick turnaround time for test result is vital in contact tracing. The average person comes in to contact with roughly 16 other people each day. If it takes 2 weeks for results to come back and for contact tracers to start reaching out, that number goes way up. Sure, some of the 16 people a day are easily recalled repeats like family or coworkers, but what about the cashier at the local grocery store? Or a friend who met for coffee? The longer it takes for test results to come back, the more  people can get infected unnecessarily. Calling this many people would take a lot of time, possibly days, so they wouldn’t be alerted immediately.

Another related challenge is asking people to quarantine until their test result come back. It is reasonable to ask people to quarantine for a day or two until their results are reported, but making people quarantine for 2 weeks with a possible case is outrageous. COVID testing and contact tracing need to work hand in hand to effectively reduce cases. This is what makes partnerships between contact tracers, community organizations and the healthcare system so important.

Growing our contact tracing tools now will also benefit us in the future. When another wave of COVID or a new pandemic appears, American cities and towns will be far better equipped.

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Telehealth, visualization and the pandemic

published date
August 6th, 2020 by
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Dr. Art Papier, VisualDx CEO

Infectious disease expert and dermatologist Art Papier is CEO of VisualDx. In this podcast interview we discuss the pandemic, telehealth, and racial disparities.

Here’s what we covered:

(0:13) Comparing today’s crisis with 9/11 and anthrax attacks
(2:06) Lack of preparation for COVID-19
(3:43) The all hazard approach to bio-preparedness
(7:04) Why COVID-19 hit the US so hard
(8:19) How the pandemic will end
(10:04) Role of virtualization in diagnosis
(13:50) What changes with telehealth
(15:58) Future potential of telehealth
(18:45) Impact of telehealth on equity and disparities
(21:08) What the future holds

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Interview conducted by healthcare business consultant David E. Williams, president of Health Business Group. Podcast production by Marina Zapesochny, social media intern.

Can pro sports beat the pandemic?

published date
August 3rd, 2020 by

 

The sudden shutdown of pro sports in March was a shock to the system that made COVID-19 real to the public at large. Wouldn’t it be nice if the restart signaled the end of the pandemic? Alas, it’s instead become a reminder of just how serious a mess we are in.

In this episode of #CareTalk, John Driscoll and I discuss

(0:12) Can any professional sport safely continue operations during the pandemic?
(1:16) The MLB’s “Fish problem”
(3:20) Can Canada do it better? (6:00)
What about the NFL? (8:43)
Where is the USA in the battle against COVID-19?

Colleges adapt porn industry policies for safe reopening

published date
July 2nd, 2020 by
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Giving it the old college try

Top colleges are taking a page from the adult film industry’s playbook to ensure that they can reopen this fall and stay open, despite the COVID-19 pandemic. I applaud them for it.

As I wrote in early April (Let the porn industry reopen the economy):

Donald Trump, the CDC and much of the rest of the federal government have demonstrated sustained incompetence on getting testing going…

The obvious answer is to enlist the adult film industry in returning the economy to normalcy. The industry has operated a testing system successfully for years to stave off threats of infections from HIV and other sexually transmitted diseases.

I went on to describe the PASS system that had operated successfully for a decade, with frequent testing and follow-up. I encouraged employers to do something similar.

Employers haven’t really taken this on, but one sector of the economy is not only adopting this approach but taking it to the next level. Some high-end private colleges and universities are determined to return to campus this fall. Online classes are ok but they are a very poor substitute for the in-person experience and are frankly not worth the tuition.

Unlike some of our red state governors, certain college presidents are taking a cold, hard look at what it will take to make it happen. They aren’t relying on science and public health experts, not wishful thinking. And they have come to the same conclusions that the porn kings did.

Here’s what Colby College is doing (emphasis mine). They expect to spend $10 million this year.

Colby’s testing program… will require the participation of all members of the campus community—students, faculty, and staff. Students will be tested prior to arrival with test kits provided by Colby, and all community members will be tested three times during the opening weeks of the semester. Thereafter, everyone will be tested twice per week, a rate that scientific models have demonstrated will greatly limit the spread of the virus by detecting infections in individuals prior to them becoming contagious. To put this in perspective, we expect to administer roughly 85,000 tests in the first semester alone, a number that almost equals the total number of tests administered in the entire state of Maine since the start of the pandemic.

…Test results will be returned to the individual and the College within 24 hours, allowing for any required mitigation efforts to be instituted quickly. We have leased additional housing for quarantine and isolation of students, who will be provided with a range of support services, including facilitating their coursework, attention to medical and mental health, and food delivery.

And Brandeis?

Brandeis will provide high-frequency, mandatory COVID-19 testing to all on-campus community members…All students living in campus residence halls will be tested upon their arrival to campus, and students living off-campus will be tested at a designated time before the start of the fall term. There will also be mandatory testing multiple times per month for all students, faculty, and staff who either live on campus or who come to campus several times per week, whether or not they are symptomatic. This will enable us to quickly identify and contain any instances of infection on our campus. Those coming to campus less frequently will also be tested, though not as frequently.

Testing is part of broader plans, but it is the core and let’s us know they are dead serious. Both of these schools are working with the Broad Institute for testing.

Interestingly, some other colleges are wavering on testing or throwing in the towel with a move to online only. Good luck with that.

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By healthcare business consultant David E. Williams, president of Health Business Group.