New Yor k M e di c a l C o l l eg e
PANDEMIC PERSPECTIVES OBSERVATIONS IN THE TIME OF COVID-19
TABLE OF CONTENTS INTRODUCTION POLITICS IN THE TIME OF COVID 5 6 7 8 9
To End the Female Recession, Women Need Their Own Rally Cry Senator Paul’s Skepticism of Experts Sets a Very Dangerous Precedent Trump’s Kung Flu Takes its Place in Chronology of Racial Fear-Mongering The Trump Rally in Tulsa is A Recipe for Disaster With COVID-19, Civil Discontent Must Not Lead to Civil Disobedience
PUBLIC HEALTH IN THE TIME OF COVID 13 15 16 17 19 20 21 22 23 24
To Stop College Students from Attending “COVID Parties” Start Asking Why COVID-Safe: Amidst the Pandemic, Look Out for Number One Improving Communication in Technology Driven Mental Health A Poignant EMS Week Amid a Historic Pandemic Amid a Pandemic, Nurses Make a Vast Difference to Improve Global Public Health NYC Paramedic Describes Holding ‘Ad Hoc Wake’ in Ambulance for Coronavirus Victim; ‘I’ve Never Seen So Many People Die in One Shift’ U.S. Picks Worst Possible Moment to Cut Funding to WHO We Need a Better CARES Package for the Elderly Weighing the Economics, Public Health Benefits of Sheltering in Place Too Little or Too Late: U.S. Senate Response to Public Health Crises
RACE, ETHNICITY, GENDER AND SOCIAL DETERMINANTS IN THE TIME OF COVID 27 29 30 31 32 33 35
Higher Education’s Misguided Obsession with Diversity Officers A Pandemic in a Pandemic: Gender Based Violence and COVID Let Ageism Bite the Dust During COVID Unspoken and Undone: Caring for Women Dealing with the Emotional Trauma of COVID-19 The COVID-19 Pandemic is Squeezing Women Out of Science When There Is Diversity Without Inclusion Human Rights and Social Inequity Issues are Magnified by COVID-19
ETHICS IN THE TIME OF COVID 37 39 40 41 43
A Pandemic Ethical Conundrum: Must Health Care Workers Risk Their Lives to Treat COVID-19 Patients? Saving Ourselves from the Groundhog Day Effect When the Current Crisis Passes, Will We All Still be Created Equal? What Happens When We Run Out of Ventilators? Jewish Law and State Guidelines May Have Different Answers The Ethical Minefield of Prioritizing Health Care for Some with COVID-19
INNOVATION AND ADOPTIVE LEADERSHIP IN THE TIME OF COVID 47 48 50 51 53 55 56 57
The COVID-19 Vaccine is Coming. But Will We Be Ready? How Tech Is Saving Lives During COVID Amid a Historic Pandemic, Public Health Must Take the Lead Even With Other Concurrent Disasters Donâ&#x20AC;&#x2122;t Disparage the Pace of COVID-19 Research The COVID-19 Pandemic: For-Profit Health Plans Win, Hospitals Lose Hospital Industry Faces Reckoning: Where Do We Go From Here? COVID-19: In the Race for a Vaccine, Biopharmaceutical Companies Showing Moral Imperative Wake Up Call For Industry Leaders: The Time To Think About COVID-19 As A Complex Adaptive Challenge Is Now
LOOKING FORWARD IN THE TIME OF COVID 61 62
Want More Women in Leadership Roles? Focus on Their Strategy and Not Their Smile Generation COVID: From the Eye of the Storm, a New Generation is Born
INTRODUCTION Jennifer Riekert, M.B.A
Vice President of Communications and Strategic Initiatives
coronavirus. With his years of public health knowledge and his calm and reassuring delivery, Dr. Amler established himself and NYMC in mainstream media as a trusted source of information on this evolving new virus. Weeks later, when the virus took root in the United States, one of the first hotspots was right in our proverbial backyard—a few miles away from the NYMC campus—in Westchester County. As time went on, our local hospitals became overwhelmed and health care providers were faced with unprecedented ethical dilemmas due to limited resources. I was able to arrange interviews between our faculty experts and top top-tier media outlets. Sitting in on these interviews, I listened as our experts needed to not only answer the reporter’s questions, but also educate them on complex medical, ethical and public health issues. However, in several instances, when the final piece went to print, an hour-long interview resulted in a one-line quote.
In early January, I was in a meeting with a faculty member from New York Medical College (NYMC), when I casually mentioned my plans for an upcoming trip abroad. She looked pensive, then after several seconds cautioned that I may want to hold-off on any unnecessary international travel. As an infectious disease expert, she was concerned about a novel coronavirus outbreak in China that appeared to cause pneumonia and was rapidly spreading. Perhaps sensing my resistance to canceling my plans, my colleague asked how much I knew about the influenza pandemic of 1918 and proceeded to tell me she was very concerned that this virus in China had pandemic potential. As the vice president of communications and strategic initiatives for NYMC, I immediately recognized this as a true public health concern and knew that our faculty experts were uniquely qualified to inform and advise the public. I called my colleague Robert W. Amler, M.D., dean of the School of Health Sciences and Practice at NYMC and former CDC medical epidemiologist, who confirmed the virus’ potential deadly reach and agreed to allow me to pitch him as an expert to speak in the media. While most of the world carried on with their regular routines, unaware of the imminent threat that would soon have a devastating impact on so many people in the coming weeks, I reached out to journalists and editors to encourage them to cover the novel
Through this experience, I realized that the media had tremendous power to deliver critical information on medical and health care issues. Yet, the public could be better served if able to hear that information directly from medical experts, rather than after it has been translated and altered through the lens of a journalist. In addition to continuing to present our experts as resources to the media, the Office of Public Relations at NYMC worked with College leadership and faculty to hone the craft of editorial writing so that they could present information to the public with their words fully intact. With NYMC’s ground-level view of this novel coronavirus, which continued to surge, it became clear that future conversations would have to be centered around what is now known as COVID-19—and I made the strategic decision to drive that conversation. By gathering several experts who could lend their voice as editorialists in the news, they would be given a platform to share their expertise and thoughts in an unedited format. As more members of the NYMC community stepped up from different backgrounds and different thought groups, our expert editorialists began delving into topics well beyond health care. We tackled everything from public health, research on vaccines, bioethics and religious values, politics and COVID-19’s impact on business and the economy. These thought pieces reached hundreds of thousands of readers throughout the United States, directly shaping the public’s view, helping to make sense of what seemed to be a nonsensical reality of seemingly endless loss, illness and economic stagnation.
NYMC faculty, in collaboration with the Office of Public Relations, created the body of work presented in Pandemic Perspectives while we were still in the darkest hours of this global crisis. Through these various viewpoints, NYMC created a bigger picture that helped to move us forward during the early days of the COVID-19 pandemic. This collection provides a historic view, a snap shot in time, during which we, as a health sciences community, were trying to make sense of the emergence of this new viral respiratory pathogenâ&#x20AC;&#x201D;the likes of which weâ&#x20AC;&#x2122;d never seen in our lifetime. A virus which has disrupted the world order as we knew it. When we are finally on the other side, when we have contained the threat, editorials like these will provide us with a record of the past with clarity that is only possible with hindsight. We will see how facing a novel viral pandemic, academics helped shape the conversation and inform the public. Pandemic Perspectives will also serve as a roadmap and a guide, should we ever face a similar outbreak in the future. We will see how we took this harrowing time and looked for ways to control the outbreak, and in the end, came out stronger.
POLITICS IN THE TIME OF COVID
To End the Female Recession, Women Need Their Own Rally Cry Jennifer Riekert, M.B.A.
Photo Credit: Getty Image
At a campaign rally in Lansing, Mich., President Donald Trump, in an attempt to appeal to women voters stated, “We’re getting your husbands back to work, and everybody wants it.” The president’s statement lays bare the misguided understanding of what women want and we as a nation need. As the pandemic rages on and the economy is in a steep decline, we are faced with the harsh reality that it is women who are being forced to exit the workforce at startling rates. The repercussions of this alarming trend have the potential of wiping out the hard-earned progress made by women and will have ripple effects that could last generations. In what is being called the first female recession, we are faced with the harsh reality that more than 800,000 women were forced to leave the American workforce in the past month alone. New research published by LeanIn.org and consulting firm McKinsey & Company spotlighted an even bleaker future, revealing that more than one in four women are considering downshifting their careers or leaving the workforce because of the COVID-19 pandemic. The uncomfortable truth is that this mass exodus is hitting women in all areas of the workforce from entry level service workers to CEOs. Women working in service jobs do not have the option of working from home and the increased exposure to the virus threatens their family’s health as well as their own. Many of them earn a wage that, while needed, may not justify the risk. For women who have the ability to work remotely, the burden of caring for children, overseeing remote education and addressing health concerns are leading to burnout. As social distancing measures have been enforced, many support systems, including child care provided by grandparents and extended family members, have been cut off while finding reliable and safe outside child care has become impossible for countless families. Faced with the impossible task of balancing the risks and demands of work, while maintaining the family unit, women, especially lower earning women, are being forced to leave the workforce.
In order for our economy to thrive, women are needed in all levels of the workforce. We must shine a spotlight on this crisis and let it serve as a wake-up call to leaders that we need to create flexible work environments as well as develop a culture that supports women. As a female executive with three children, I often feel like my mantra for success has been to “work like I don’t have children and mother like I don’t have a career.” Now that I am working remotely it is not uncommon for one of my children to walk into the camera frame on my Zoom call to ask me when I’m going to make them lunch, while I am trying to lead a staff meeting from the laptop in my kitchen, dissolving the illusion that I am solely a one dimensional professional that only exists in an office environment and revealing that I am also a mom with my private world on display. Women have the tendency to put themselves on mute during Zoom meetings to block the background noise children may be making, but this also serves to limit their voice in discussions and decision making. As leaders we need to be conscious of the blurred lines remote working has created and look for ways to engage female workers. Ensuring women are involved in decisions that need to be made to address the challenges of the pandemic regarding reopening plans, paid leave policies, flexible work schedules and changes in performance review processes is vital. Organizations should take this as an opportunity to revisit their mission and vision to ensure it addresses the unique challenges we are facing and resonates with their audience. When people feel meaning in their work and a sense of purpose, they are more likely to stay engaged. The best retention strategy for organizations may be empathy. Find ways to ensure employees feel heard and understood. Allow flexible work schedules, grant time off, provide mental health services, create mentoring opportunities and reach out to people to ask how they are faring during this challenging time. Organizations will not be able to turn the tides of this female recession alone. It will require a shift in culture. The responsibility of raising a family and managing a household needs to be viewed as shared and not primarily shouldered by women. Closing the wage gap between male and female workers is a necessity we can no longer afford to ignore. Our most important resource in this crisis will be our voice. We need our own rally cry — speak up for what women want, what we need. We not only need women back to work — we need to stand at podiums, sit in boardrooms, raise our families and chart a brighter course for the sake of generations to come. As appeared in The Hill on October 30, 2020.
Senator Paul’s Skepticism of Experts Sets a Very Dangerous Precedent
Why should experts guide our national response to COVID-19? Maybe you missed that lecture in medical school, Dr. Paul. It’s because experts know more about it than you do.
Edward C. Halperin, M.D., M.A.
‘Decentralized Power’ in Public Health
Photo Credit: Nicholas Kamm/AFP
During US Senate hearings in March and June, Senator Rand Paul of Kentucky, a Republican and an ophthalmologist, voiced multiple criticisms of Dr. Anthony Fauci. For the last 34 years, Fauci has served as the Director of the National Institutes of Allergy and Infectious Disease. For many Americans, he has become the face of medical expertise regarding the COVID-19 pandemic. Pointedly critical of his recommendations on slowing the COVID-19 spread, Senator Paul ridiculed Fauci’s expertise, hurling combative comments such as: “We shouldn’t presume that a group of experts somehow knows what’s best for everyone.” “I don’t think you’re the end-all. I don’t think you’re the one person who gets to make a decision.” “Only decentralized power and decision-making, based on millions of individualized situations, can arrive at what risks and behaviors each individual should choose. That’s what America was founded on — not a herd with a couple of people in Washington all telling us what to do, and we like sheep blindly follow.” Paul decries reliance on experts. It’s a dangerous precedent for a US Senator to take. If one follows Paul’s logic, why should we only allow “certified experts” to pilot passenger aircraft? If the plane is about to take off and the voice overhead says, “Ladies and gentlemen, I’ve never flown one of these, but read an article about how this works… so buckle up,” would Paul settle in for his flight? Maybe he’d like the plane flown by a “decentralized” vote of the passengers?
Paul is also wrong about “decentralized power” in the realm of public health. Public health authority in the US is already highly decentralized to states and county health authorities. In countries that actually exert central leadership in the face of a pandemic, like Germany, ventilators, ICU beds, and testing are handled far more efficiently and with less loss-of-life than under the gang-who-can’t-shoot-straight pandemic management style of Donald Trump’s administration. Paul’s skepticism of “experts” is particularly curious insofar as he is a physician himself. Medical specialists demonstrate their expertise by achieving board certification by recognized national organizations. For example, I am board certified as a radiation oncology physician by the American Board of Radiology. Cardiologists are board-certified by the American Board of Cardiovascular Medicine and ophthalmologists by the American Board of Ophthalmology. How about Rand Paul? As has been widely reported in the press, he never achieved certification by the American Board of Ophthalmology. Instead, he invented his own board, called it the National Board of Ophthalmology, helped write the questions on the “board examination,” took it himself as an open book take-home examination, certified himself, and installed his wife and father-in-law as officers of his self-created “board.” His certification house-of-cards long ago collapsed. For someone with both so little respect for the concept of documentation of medical expertise, and so little demonstration that he possesses any understanding, to publicly criticize the COVID-19 expertise of Dr. Fauci, one of the world’s leading experts on infectious disease, would be funny if Paul didn’t take himself so seriously. Fortunately, most public health experts, physicians, and the American public do recognize both the value of expertise and Dr. Fauci’s service to his country.
Perhaps he thinks we should ignore nuclear engineers and allow the operation of a nuclear reactor to be placed in the hands of anyone who has some free time on their hands?
Dr. Paul graduated from Duke University’s School of Medicine during a period when I was on the Duke faculty. I have no recollection of him as a student. He must have been bright enough to get admitted. He also illustrates a pronouncement of my father, who expressed an opinion within his area of expertise: “There are bright people in this world who don’t have any common sense.”
Would he prefer to drive his family on a bridge over a canyon designed by anyone who owns a pencil and a piece of paper or, instead, rely on a civil engineer with years of experience in bridge design?
As appeared in The Globe Post on July 13, 2020.
Trump’s Kung Flu Takes its Place in Chronology of Racial Fear-Mongering Edward C. Halperin, M.D., M.A.
Photo Credit: Nicholas Kamm/AFP
At Donald Trump’s indoor campaign rally in Tulsa, Oklahoma, attendees were neither required to maintain social distance nor wear masks, blatantly disregarding previously established pandemic control guidelines. These guidelines were established by our nation’s top infectious disease physicians, including Dr. Anthony Fauci and other members of the White House Coronavirus Task Force. In a rambling speech delivered by Trump, who also did not wear a mask, he referred to COVID-19 as the “kung flu.” He has previously called it the “Chinese virus.” During the rally, he also stated that he had asked government officials to “slow the testing down” for COVID-19 to reduce the reported incidence rate of the disease. As a medical historian, I immediately recognize and recoil from anyone labeling diseases with names that disparage racial or religious groups. Behavior of this type occupies a dark place in medical history.
Attaching Racist Names to Diseases During the 14th century, the Black Death killed about a third of Europe’s population. Most modern medical historians agree that the bacteria named Yersinia pestis caused the Black Death. It was a form of a rapidly progressing disease, which we would now call plague. In the 14th century, however, no one blamed bacteria. Instead, they erroneously blamed the Jews. Large-scale massacres occurred of Europe’s Jews – a period of wholesale slaughter which, in its time, presaged the Holocaust of the 20th century. As syphilis spread across Europe in the 15th century people took turns scapegoating each other. The Germans called it the “French Disease” while the French called it the “Italian disease.” Anglo-Saxon Protestants blamed cholera outbreaks in the United States in the 19th century on Roman Catholic Irish immigration.
The British medical historian Niall Johnson has written that some people try to portray disease as,
“foreignness…What is wrong or unnatural cannot be of us, but must be of the ‘other’… One of the most obvious expressions of such externalizing of blame is when a geographical name becomes attached to a disease. The name suggests both disease and blame.” When President Trump referred to an encapsulated RNA virus as “kung flu” rather than COVID-19, he was trying to shift blame from poorly formulated and incompetently executed public health policy (included his wish to suppress COVID-19 testing), and instead place that blame on the people of Asia. In so doing, he is reincarnating a distasteful late 19th century epithet directed against Asian immigrants to the United States: the “yellow peril.”
‘American Lung Cancer’ Of the four plants of the Americas that spread to the rest of the world following the arrival of Christopher Columbus – potato, maize, tomato, and tobacco – only tobacco has successfully spread to reach everyone on the planet. Tobacco use is responsible for a significant proportion of cancer, cardiovascular, and pulmonary disease and death. How would the citizens of the United States feel if, instead of calling the disease “lung cancer,” the rest of the world adopted the term “American lung cancer?” Would we like it if cigarette-induced emphysema were named after a tobacco-producing state along the lines of “Kentucky Air Hunger Disease” or “North Carolina suffocation?” I think we would be deeply offended. Blaming diseases on racial, religious, or national groups is no joke. Innocent people get beaten or killed because of blame-shifting. We have already seen assaults in our country against Asian Americans as a result of this propensity to use racially charged language. In the midst of a crowd standing far too close to one another while not wearing masks, Trump injected the disease of racial hatred into the already virally infested airborne droplets that were being disseminated in that indoor arena in Tulsa. People of goodwill must oppose the disease of racism as vigorously as they combat the viral pandemic. As appeared in The Globe Post on June 29, 2020.
Why do some people attach racist names to diseases?
The Trump Rally in Tulsa is a Recipe for Disaster
stay-at-home period begun on March 23 in New York State followed by an incremental phased approach to re-opening which started on May 15.
George W. Contreras, M.E.P., M.P.H., M.S., CEM, FAcEM
Even the economy is showing signs of improvement as the Dow Jones surpassed 26,000 on June 16. We are making progress, yet these signs of improvement will quickly disappear if the number of daily cases and hospitalizations begin to rise again across the rest of the nation. President Trump’s decision to hold a rally in a crowded indoor venue is misguided. It sets the stage for a high-risk situation that can harm thousands in one fell swoop — not to mention their thousands of contacts.
Photo Credit: Win McNamee/Getty Images
President Trump is set to hold a rally Saturday evening inside the 19,199-seat Bank of Oklahoma Center in Tulsa, Oklahoma. The country is still in the middle of a historic pandemic. Cases are spiking in Oklahoma. And there’s no treatment for the disease or vaccine against it. The rally is a recipe for disaster. Here are the three key ingredients: An indoor event. Instead of holding the event outdoors, it is being held indoors in a center that regularly crowds people together for concerts and sporting events. No physical distancing. The president has touted that his campaign has already received more than one million requests for seats. And he has mentioned that only 22,000 people (or even up to 40,000 if he can get the adjacent convention hall) will be allowed to attend. Someone needs to check that math because 22,000 — already 2,800 people above capacity — signifies there will be no physical distancing in place. No masks. Trump has also reported that those attending the rally will not be required to wear face masks. With all this bravado, it is curious that those who plan to attend must sign a waiver that the White House will not be held liable if they fall ill with COVID-19. According to the Centers for Disease Control and Prevention, which created categories to evaluate the “riskiness” of activities, having a mass gathering in an indoor venue without wearing face coverings and being unable to practice physical distancing is the highest possible risk. In a little over 100 days, 2.1 million Americans have been diagnosed with COVID-19, and nearly 120,000 deaths. Amid the fear and frustration, a bright spot has been emerging in the Northeast, where COVID-19 cases in New York and surrounding states have been steadily trending downward. One key reason for this is the
It is, however, a reflection of the growing complacency of some throughout the country, which has caused states such as Arizona, Tennessee, Texas, and California to see an uptake in daily cases. As of June 16, more than 20 states are seeing daily increases in the number of new cases. Cases can increase due to engaging in large gatherings, not wearing masks properly or not wearing them at all and not keeping six feet distance. Disregard for physical distance and wearing face coverings has been seen in Nashville, New York City, and San Marcos, Texas, to list just a few examples. The efforts of the hard work over the past few months are being lost due to overzealous leaders and individuals who are not keeping their guard up. The protests and mass gatherings that took place in the aftermath of George Floyd’s killing in Minneapolis are also worrisome from a public health perspective. Many people taking part in these events have not been wearing face coverings, meaning the gatherings could serve as super-spreader events and cause an increase in COVID-19 cases where they take place. Forward-minded elected officials have encouraged protesters to get tested as soon as possible. This is a good idea, but it doesn’t prevent protesters from getting COVID-19. The utility of such testing is to identify those who were infected with the virus so they can self-quarantine and not spread it to others. It’s also important to keep in mind that getting a diagnostic test one day after protesting is futile — appropriate time needs to pass in order to get accurate results. This monitoring for when to get tested has become even more complicated as the CDC has recently reported that 35% of people who test positive for COVID-19 do not have any symptoms. The underlying theme here is that you cannot know who is infectious. So we all need to take proactive measures that have been proven to offer protection against the novel coronavirus. Ignore them at your peril. As appeared in STAT on June 20, 2020.
With COVID-19, Civil Discontent Must Not Lead to Civil Disobedience Ira J. Bedzow, Ph.D. Adam E. Block, Ph.D.
Medics and hospital workers tend to a COVID-19 patient outside the Montefiore Medical Center Moses Campus in the Bronx, New York City. Medics and hospital workers tend to a COVID-19 patient outside the Montefiore Medical Center Moses Campus in the Bronx, New York City. Photo: John Moore, AFP The government’s role is to take on challenges that are larger than ourselves. COVID-19 is one of those challenges, requiring us to sacrifice our basic freedoms to engage in the outside world and destroy millions of businesses and jobs to ensure the pandemic does not kill millions in the next few months.
Photo Credit: Jeff Kowalsky, AFP
People all over the United States are voicing their anger over some of the public health policies that states and local governments are enacting to slow the spread of COVID-19. They are protesting and calling for public demonstrations of civil disobedience. American 19th-century philosopher Henry David Thoreau’s essay Civil Disobedience is one of the great pieces of American political literature. It influenced not only today’s opponents of COVID-19 oppression but also leaders such as Dr. Martin Luther King Jr. and Mahatma Gandhi. Thoreau’s words inspire, and in them, one can see both the desire to fight against injustice as well as a motivation to take respiratory risks by gathering without keeping social distancing. He writes,
“I was not born to be forced. I will breathe after my own fashion. Let us see who is the strongest.” Yet, while Thoreau’s message can be best summed up in his introductory motto, “That government is best which governs least,” we must recognize the limits of an ineffectual or absent government when it comes to issues of common goods – things that provide public benefit yet are nevertheless limited.
Government’s Role During COVID-19 Governments are not good at figuring out whether a town can support a new pizza place or whether iPhones are superior to Androids. Private goods are best left to the market to determine their value and their supply. However, when events occur that demand massive coordination of millions of people and an intensive shift of resources, markets have limited power and ability to achieve the best possible outcomes. Individuals act in their self-interest, but when a community requires real sacrifice from those who are able to supply necessities to others, it is government alone that can succeed.
No company wants to shut down, and no person wants to be shut in, but without a vaccine, with no real treatment, and with virulence and lethality we have not seen in a century, only government with its power to keep people at home can solve this problem.
U.S. Government Response Today, in response to the challenges brought on by COVID-19, the U.S. government should do what it does best. It should fund and prioritize the allocation of resources to ensure individuals’ sacrifice is minimized and the public will successfully weather the current hardship. Specifically, the government should make rules that are best for the community, not for particular individuals. Individuals will always oppose regulations that they do not like, and some will do so even at the community’s expense. The authorities should not place the priorities of the few over the interests of everyone. The government should fund science to expedite a cure and vaccine, and use the Defense Production Act to ensure health care workers are protected when they put themselves in harm’s way to care for others. Lastly, the government should borrow and print money and distribute it liberally to those who can no longer pay for food, shelter, and utilities because of the pandemic.
Not Unprecedented We have leveraged the power of the American government to save the nation from physical and economic threats before. This is not unprecedented. In World War II, a generation of men was drafted and sent overseas to fight for the preservation of freedom and democracy in the world against an enemy focused on domination and subjugation, who were guilty of actual atrocities against liberty and humanity. The U.S. government not only mobilized a military force, but also created vast networks of funding through war
bonds, and prioritized the manufacturing supply chain through the Defense Funds Act. It also established a team of elite scientists and engineers in the Nevada desert to find a new technology to utilize in the war effort. Twenty-five years after World War II, the U.S. government sent a man to the moon, and 40 years later, the government helped the U.S. heal from the terrorist attacks of September 11. Markets alone could not have achieved those feats, nor could philanthropic billionaires. Only an effective government is capable of mobilizing an entire country to carry out a seemingly infinite number of tasks – many dangerous, others requiring sacrifice – to promote the public good. Like World War II, the government response after that September 11 attacks, and more recently, Superstorm Sandy, we never thought this could happen. But it is happening. Quickly. And the best tool to contain COVID-19 is the government. As Thoreau also writes in his essay, “Governments show thus how successfully men can be imposed upon, even impose on themselves, for their own advantage. It is excellent, we must all allow.” As appeared in The Globe Post on April 29, 2020.
PUBLIC HEALTH IN THE TIME OF COVID
To Stop College Students from Attending “COVID Parties” Start Asking Why Alan Kadish, M.D. Robert W. Amler, M.D., M.B.A.
In the COVID-19 era, attending large social gatherings without a mask has been called the new “public smoking.” It’s an apt comparison considering the decades-long fight to convince smokers to refrain from smoking in public areas, despite definitive research that proves the dangers of second-hand smoke. Ultimately, public smoking was largely eradicated across the U.S., when the public health community looked to understand why people were so resistant and created programs with those specific attitudes in mind. In this same manner, it is time for higher education leaders to adopt a strategy aimed at understanding why college students are so resistant to social distancing in order to modify their behavior.
Why College Students Take Risks In Order to Socialize Nearly seven months into America’s COVID-19 crisis, large swaths of the U.S. population are (finally) serious about social distancing and mask-wearing as a means to protect each other from the virus. Not so for America’s college-aged students who continue to socialize in large groups. From the East Coast to the West Coast, and everywhere in between, college campuses are the new COVID-19 hot spots. The overwhelming response of college leadership across the nation has been to create the strictest of policies and dole out harsh punishments in the desperate hope of changing student behavior. Yet flouting the threat of suspensions and expulsions, disregarding wide-reaching educational campaigns and remaining undeterred in the face of rising numbers of COVID-19 related deaths, students still doggedly resist all attempts to alter their behavior in order to stop the spread.
This August, along with the majority of other colleges we became aware that a group of incoming students at one of our campuses ignored the College’s explicit rules. Faced with this dilemma, our leadership consulted with experts and decided that instead of jumping to immediate suspension or expulsion, we would require the rule-breaking students to meet with a physician to ensure they were fully aware of the campus policies as well as the health risks associated with ignoring the rules. Then, in consultation with mental health professionals, we had the students participate in personal interviews with physicians and a psychiatrist to get to the root of why they were willing to jeopardize their own health, the health of others and potentially their future careers. The overwhelming theme that emerged in discussions with our students was that they wanted to feel socially connected as they began their first year in school. They worried that missing this opportunity could impact their ability to form friendships, create a professional network and perhaps even hinder their future careers. They also did not want to be left out of cliques According to Steven Pirutinsky, Ph.D., professor at Touro College Graduate School of Social Work, social interaction is a critical developmental task for college-age young adults. At this stage of life, they are forming social relationships and building networks for their futures. Social stimulation is a key part of that developmental stage and an activity they don’t want to miss. Additionally, there is much evidence showing that in the early 20’s the brain has not fully developed the capacity to monitor and control behavior. Impulse control, self-regulation and long term thinking are cognitive abilities that continue to develop into the 20s A third factor is perceived lack of risk. When students are deciding whether to attend a party, they calculate risk and generally speaking, college and graduate students perceive that they are not at risk of developing serious cases of COVID 19. They make decisions based on their perceived personal risk, not the public implications of their behavior. Even adult brains are designed to evaluate personal concerns first, and less to consider broad statistical risks on which public health is focused. The reckless behavior we are now seeing in young adults reflects a mismatch between the type of problem we are facing and the type of thinking they do.
Lessons Learned— Creating Community to Stop the Spread Now, armed with an understanding that our students were willing to risk their health, suspension and even expulsion because they perceived a high-cost of forgoing normal socialization, we realize that creating real, meaningful opportunities to socialize and connect, rather than strict punishments, is the key to stop the spread on campus. Our public health approaches should take this perspective into account. College leaders must try to develop virtual alternatives that would satisfy the need for socialization while minimizing risk. To alleviate student worries about their future careers, schools can provide mentorships where the mentor and mentee schedule regular zoom meetings, student counselors should also be available by zoom as a safe space to address student concerns. Clubs and other extracurricular activities do not have to be put on hold entirely during corona. There are many software solutions to hold virtual meet and greets, trivia nights, virtual fitness classes, movie nights, game nights, book clubs, or religious services to offer a few ideas. With a little creativity, institutions can cultivate a sense of belonging and connection among students and faculty. Ultimately, as some degree of “sanction” was appropriate, our students were asked to perform community service in a COVID-safe manner which delivered a lesson and had the added benefit of making them feel socially connected. It’s important to remember, when talking about safety and risks, our messages should not simply rely on the medical model (“as your doctor I’m telling you what to do/not do). Large numbers and statistics will not impel them to change behavior. Instead, we need to make it personal. Find anecdotes of young people, or loved ones, who have gotten severely sick to make the point. To deliver the most persuasive argument, make the messages emotional, immediate and personal to compel students to make the necessary changes to keep us all safe and healthy. As appeared in University Business on October 8, 2020.
COVID-Safe: Amidst the Pandemic, Look Out for Number One Robert W. Amler, M.D., M.B.A.
If you never test positive for COVID-19, even if you completely escape this deadly viral infection, your health could still be the biggest casualty of the global health crisis. During this pandemic—amidst the dictates to shelter in place and government directed lockdowns, maintaining good health goes beyond staying clear of exposure to COVID through social distancing, masks, and hand hygiene. Months into the crisis, we now know COVID is extra perilous for people with underlying health problems, especially diabetes, high blood pressure, heart disease, and obesity. So, if you have one or more of these problems you must look out for Number One by getting any of these underlying conditions under the best possible control to improve your odds if the COVID virus comes knocking. That’s an obvious necessity. But what other COVID threat affects us all? It turns out, looking out for Number One is important in another way. Taking good care of yourself, through basic preventive measures and regular health care is not a new concept—but one that seems to have been forgotten in the wake of our recent global health threat. Now, as we emerge from lockdown, medical and public health experts agree it’s time to return to regular healthy activities, resume scheduled screenings and other preventive care, and follow up any pending medical issues that might have been postponed because of recent disruptions caused by response to the virus. As a young medical epidemiologist at the Centers for Disease Control and Prevention (CDC), my first nationwide health study estimated that up to 60 percent of deaths and severe illnesses in the United States were potentially preventable by reducing risk factors such as high blood pressure, diabetes, obesity, tobacco use, motor vehicle injuries, alcohol overuse,
drug overdose, and diabetes. The CDC confirms this percent persists today, estimating more than 1.5 million deaths per year, more than ten times the current COVID-19 deaths, and $2 trillion in health care costs. Some of the same risk factors also predict severe COVID-19 disease and need to be brought under control as well. Fortunately, many risks can be selfmanaged and in many cases can be reduced or even eliminated. Therefore, we should not let the COVID-19 pandemic interrupt preventive health care anymore than necessary. A reoccurring concern, echoed by many of my colleagues—including my colleague Renee Gerrick, M.D., the vice dean at New York Medical College School of Medicine and chief medical officer at Westchester Medical Center Health Network, “Heart disease didn’t disappear in this country; unfortunately, cancer didn’t go away.” Yet some people are fearful of exposure to COVID-19 if they seek medical care, despite telemedicine options, careful sanitizing of waiting areas and exam rooms, personal protective equipment (PPE) for providers and clients, reduced-capacity scheduling, and other safety procedures in medical facilities. Loss of jobs and health insurance have compounded the problem for many. With or without COVID-19, both longevity and quality of life are better with essential preventive health care. Among the lifesaving measures are vaccines, tobacco cessation, exercise, alcohol/drug rehabilitation, dietary guidance, driver safety, reproductive health, cancer screening and prompt detection of other conditions. These are tried and true steps to better health that add years to life and also add better life to years. The flip side, if regular health care is suspended for too long, could be a regrettable increase in major medical crises and deaths from heart disease, stroke, cancer, and chronic diseases. Looking out for Number One, by taking care of yourself and any medical issues, will help block COVID-19 from severely harming you, but also from the harm in delaying the essential health care and medical follow up you need. As appeared in Healthcare Business Today on July 24, 2020.
Improving Communication in Technology Driven Mental Health Vikas Grover, Ph.D., CCC-SLP Padmini Murthy, M.D., M.P.H., M.S. Saurabh Somvanshi, M.D.
services.. The needs of mental health patients may vary extensively according to their diagnoses. Providing these services online might require tremendous planning, expertise, availability of resources and time. The quality of provider-patient communication is expected to play an essential role. Some challenges in face-to-screen sessions and telephonic conversations include: a) difficulty in thorough understanding of the client’s affect and emotional experience, b) technical limitations (e.g., the quality of voice transmission may mask the nuance of affect, and flickering and loss of signal in video streams can interrupt the flow of conversations).
Tips for Your Telepractice
Technology and Mental Health The COVID-19 pandemic has restructured how individuals are seeking mental health services. Telepractice has existed for years but was not considered the preferred method for providing services. It has unexpectedly become a front-line tool for providing services to individuals in need. Some unexpected by-products of the current pandemic are not fever, cough, or other physical symptoms. It is the economic, mental, and survival stresses that have created a downward spiral for vulnerable populations. The crisis has resulted in an alarming global increase in gender-based violence (GBV), a silent pandemic existing in the shadows of COVID-19. According to the World Health Organization (WHO), the violence experienced by women during a pandemic has both short- and long-term effects on their physical, sexual, reproductive and mental health. Unwanted pregnancies, increased risk of sexually transmitted diseases and physical trauma by abusers are some examples of what vulnerable populations are facing. The impact of COVID-19 on mental health includes increased anxiety, higher incidence of substance abuse, self-harm, sleep disturbances and suicidal/homicidal tendencies.
Mental Health During a Pandemic This pandemic has far reaching effects, putting stress on those helping on the front lines, and those who need help but may not be receiving it. How do you administer mental health help under the burden of a worldwide pandemic? One step in the right direction is clear communication via the use of telepractice when providing mental health services. Fong Ha et al. (2010) suggested that “effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine.” This statement is more crucial than ever with the rise of telepractice. New York State Governor Andrew M. Cuomo announced that 6,175 mental health workers have volunteered in New York to provide free online mental health
We need to embrace these challenges and explore the possibilities to create effective treatment sessions. Here are some suggestions based on our experience and feedback from patients and families. Maintain the therapy frame, including a professional backdrop and follow the regular assessment format (active, compassionate and non-judgmental listening). Undoubtedly, some body language, and physical cues might be missed in telepractice, but a patient’s home situation and behavior in their natural environment can reveal an individual’s personal challenges. Seeing patients in their homes and their element, something akin to the age-old practice of home visits, adds a new dimension to the therapist-patient rapport. Visualizing a person within the context of their environment can increase active listening and enhance reciprocal communication. Clear and organized communication can improve doctor-patient relationship via telepractice. Allowing the appropriate amount of time and providing feedback are crucial elements for avoiding communication breakdowns. Communication needs to be empathetic, timely, open and free of judgment. Communication strategies should be tailored to individuals.
Embracing the Future of Mental Health Before starting telehealth services, providers should establish an environment that will prevent physical exhaustion which will accumulate throughout the day. Evaluate the ergonomics of your setup and the proximity of materials you may need during the session). It is helpful to keep some extra time between sessions and maintain a list of the approved online platforms to provide options to your patients. Use high-quality headphones and microphones. In most video-based apps, by default, patients and providers see a small window on the screen, quite different from in-person settings. It is vital to emphasize that seeing patients remotely instead of in-person is not a sign of helplessness due to this pandemic. It is an immediate support to those in need of mental health aid in the moment. As appeared in Different Brains on June 9, 2020.
A Poignant EMS Week Amid a Historic Pandemic George W. Contreras, M.E.P., M.P.H., M.S., CEM, FAcEM
National EMS Week is an annual event throughout the United States which celebrates and recognizes the hard work that all EMS providers do on a daily basis – from emergency medical technicians (EMTs) up to paramedics. These EMS providers can be paid, volunteer or a both (but at different agencies). No matter what the level, just remember that this person made a conscious decision to help someone in need, even while putting themselves (and/or their loved ones) at increased risk. During this ongoing COVID-19 pandemic across the country, the acts of courage, dedication and compassion could not have been clearer. On the east coast, New York, New Jersey and Connecticut contributed a large percentage of the total cases and deaths in the United States. To look even deeper, New York City (at the epicenter of New York State and the United States) and its EMS system was deeply impacted. When I meet people at a conference or seminar and I tell them that I am paramedic in New York City, the majority of the time I get: “Wow, so you work for FDNY?” I immediately inform them that I do not work for the Fire Department of New York (FDNY), but I am still a paramedic in the 911 system in New York City. In order to remove that confused look from their faces, I quickly jump into my educator mode and provide them an overview of the 911 EMS system in NYC. From 1970 to 1996, the NYC Health and Hospitals Corporation (HHC) had oversight of the EMS in NYC and it was known as NYC EMS. Then in 1996, for a myriad of reasons and contributing factors, the FDNY took over EMS and absorbed its operations. There are now two main divisions: suppression and EMS. And just like that, FDNY EMS was born. Many people (including some New Yorkers) do not realize that New York City does not have enough total resources to respond to
the 1.8 million EMS calls (as in 2018). Private hospitals in NYC provide approximately 35% of the personnel and ambulances that respond to NYC 911 EMS calls in collaboration (via contract) with FDNY EMS who provides the remaining 65%. Together private hospitals and FDNY EMS provide the 911 EMS to the residents and visitors of New York City. Some hospitals also subsequently subcontract with private ambulance companies who work and represent the hospital while providing the emergency service. So, someone such as myself who works for a hospital (for almost three decades) is still a 911 NYC paramedic in one of the largest and busiest EMS systems in the world. All EMTs and paramedics (regardless for whom they work) are certified by the New York State Department of Health Bureau of Emergency Medical Services (NYS DOH BEMS). The Regional Council of EMS in NYC (REMSCO) issues the protocols by which all personnel must follow while adhering to NYS DOH BEMS statewide protocols. FDNY EMS also has its policy and procedures for its members and participating hospitals. Over the past ten years, the annual call volume has steadily increased with 2018 having the highest annual volume of 1.8 million calls. Previously the highest call volume within a 24-hour period was on September 11, 2001. During the peak of the pandemic in late March and early April, the daily EMS call volume reached unprecedented records and even surpassed 7,200 (including administrative entries) calls within a 24-hour period. This unprecedented territory of high call volume combined with staff shortages (due to quarantine or actual sickness) among EMS and the hospitals overwhelmed with surge capacity resulted in various protocol changes which drastically changed how we performed our duties. I commend the NYC REMSCO for taking actions to protect all EMS providers during these times of crisis. Some of the specific disaster protocols in NYC included modifying cardiac arrest protocols, recommending patients with mild symptoms to stay home, modifying ambulance staffing levels, extending current certifications and even recertifying personnel with recently expired credentials. All of the COVID-19specific policies have since been rescinded and we are back to pre-COVID-19 operations. At the peak of the first wave, it was even necessary to activate the National Ambulance Contract (NAC) and soon there were additional ambulances and EMTs and paramedics from all over the United States. It was so surreal to see out-of-state license plates and different uniforms patrolling the streets of New York City. I want to send those out-of-towners a special thank you for coming to assist us in our darkest hour.
To see refrigerated 53-feet trucks parked outside of most NYC hospitals was a constant reminder of just how overwhelming this pandemic has been. These trucks served as additional morgue surge capacity for hospitals which generally do not have much space for the deceased. The USNS Comfort and the use of the Jacob Javits Convention Center were also signs of the troubled times as it provided care to the surge of patients with COVID-19 from the overwhelmed hospitals. Expected physical and mental health consequences from working long hours under these difficulty conditions and lack of sleep and healthy diet will all contribute to lowering the immune system of the providers at a time where we need them to be as strong as possible. We need to acknowledge and prepare for the emotional and mental health toll that this prolonged exposure can and will have on our EMS providers. We need to take advantage of this lull and prepare for the next wave. We cannot be caught off guard again. All EMS personnel demonstrated outstanding courage and dedication in the wake of danger. But the human aspect of what these conditions will do cannot be overlooked. Because at the end of the day, every EMT and paramedic are still human beings with families that they want to protect even more than the patients they serve. To date, there are several EMS providers who have recovered but others are still in quarantine, hospitalized, and even intubated. Sadly, we may also know of an EMS colleague who has died from COVID-19 exposure. We must remember those who have died during this pandemic including seven NYC EMS providers: EMT Greg Hodge, EMT John Redd, EMT Richard Seaberry, EMT Idris Bey, EMT/EMD Marlene Picone, Paramedic/RN Brian Saddler and Paramedic Anthony Thomas. I personally knew Marlene, Brian and Tony and will miss them all. May we remember all EMS providers who died from COVID-19 across this country. I can only hope that we will not suffer additional losses but I am not too confident in making that statement. I hereby salute all EMTs and paramedics during this 2020 EMS Week whose theme is so appropriately â&#x20AC;&#x153;Ready today. Prepare for tomorrow.â&#x20AC;? Now more than ever, we need to make this theme matter. Let us learn from our experience and put it to good use. We owe it to those who made the ultimate sacrifice during this pandemic. As appeared in Journal of Emergency Medical Services on May 21, 2020.
Amid a Pandemic, Nurses Make a Vast Difference to Improve Global Public Health
Nurses have been described very often as a bridge to healthcare for people in their communities. They practise on the frontlines of primary care and acute care. Nurses have a long history in the prevention of illness.
Amy Ansehl, M.S.N., D.N.P., FNP-BC Padmini Murthy, M.D., M.P.H., M.S.
Nurse leaders such as Lillian Wald understood the value of the patient’s environment, and how their socioeconomic status, access to clean water, food and shelter contribute to the exacerbation of disease and mortality. Today this understanding of environmental impacts of disease is termed the social determinants of health.
At the dawn of this decade, the nursing profession is stepping up, once again, to meet the significant challenges of a new public health pandemic. The coronavirus pandemic has thus far recorded more than 3.6 million cases worldwide and greater than 250,000 deaths. Amid this pandemic, where nurses are heavily involved in the saving lives on the front lines of the fight against COVID-19, it is apropos that the World Health Organization (WHO) has designated the year 2020 as the International Year of the Nurse and the Midwife. This isn’t the first time the nursing profession stepped up to meet overwhelming public health challenges. Two hundred years ago, one of the nursing profession’s most notable, strategic and innovative leaders was born. Florence Nightingale was a social reformer, statistician and nurse innovator who changed the way nursing, medicine and public health practitioners used their skills in their practice to save lives. Ms. Nightingale challenged the long-established thought on patient care by implementing a novel approach to patient care that focuses on a trifecta of priorities: hygiene, sanitation and fresh air. The Crimean War served as an opportunity and platform for Nightingale to not only put into practice environmental sanitation and hygiene controls but advance strategies for integrating mental health and into the treatment and recovery plan. Back in 1853, Nightingale understood and trained a cohort of nurses to assess the patient holistically, with mental health status recognised as an integral component of patient wellness. Nightingale’s Notes on Nursing provided practical guidance for combatting sickness and disease, which included the need for fresh air and ventilation, sunlight, nutrition, hygiene and sanitation. She emphasised the importance of frequent hand washing and cleaning the patient and their environment.
“Nurses have a long history in the prevention of illness” Nightingale took her beliefs even further by advocating for policies that incorporated these beliefs so they could be implemented locally. She understood that if we do not translate these individual health promotion strategies and have local governments adopt them as policies, we will be unable to prevent the spread of disease.
Ms. Wald was an American nurse, an advocate of human rights, and innovator. She founded the Henry Street Settlement in 1893 which served as a beacon of light for the swelling immigrant population. The Henry Street Settlement, which is still in existence today provided social services, education and healthcare to hundreds of thousands of low income and economically disadvantaged families.
“More than ever, the global community needs to realise the important contributions made by the nursing workforce” Based on her work at the Henry Street Settlement, Ms Wald founded the Visiting Nurse Services of New York. Thus, creating an essential and sustainable home healthcare industry that employs nurses, doctors, physical therapists, occupational therapists and speech language pathologists worldwide. Wald advocated for children, women’s rights, minority populations and labour. She was instrumental in the founding of the NAACP (National Association for the Advancement of Colored People), the United States Children’s Bureau, the National Child Labor Committee, and the National Women’s Trade Union League. How is this applicable to the challenges facing us globally? More than ever, the global community needs to realise the important contributions made by the nursing workforce in their tireless efforts to achieve the targets of the United Nations’ goal to achieve sustainable development by ensuring health lives and promoting the wellbeing for all. Especially, amid the tremendous global challenges unleashed by the coronavirus pandemic, the first line of defenders are the health professionals. Physicians, nurses, home health aides and physician assistants are the most valuable resource in our fight to preserve public health in the wake of coronavirus. Thus, it is crucial that nurses, along with all first responders, get a seat at the table when public health policy is created, and guidelines are enacted. As appeared in Nursing Times on May 7, 2020.
NYC Paramedic Describes Holding ‘Ad Hoc Wake’ in Ambulance for Coronavirus Victim; ‘I’ve Never Seen so Many People Die in One Shift’ George W. Contreras, M.E.P., M.P.H., M.S., CEM, FAcEM
So on this street corner in New York City, in the middle of the night, I decided to allow the family to say their final goodbyes right there in the back of the ambulance. I never thought my ambulance would become an ad hoc funeral home and be the site for a wake in the middle of the night. It doesn’t offer any closure. It made me well up. A wave of emotions came over me. I’ve seen people that live in homes, live in small apartments, multi-generational households. From young kids to their parents to the grandparents, all living in small quarters. I’m taking care of this person who’s really, really sick — and there are about 12 or 15 other people who have been pretty much not practicing, or not able to practice, social distancing. All those people who die on a daily basis — each one is not just a number. Each one is a person, and that one person will have had a huge impact on the inner circle of their family and friends, which could be 100, 200, 500 people.
Photo Credit: Theodore Parisienne/for New York Daily News
I’ve been a paramedic for a private hospital in New York City for 30 years, but until COVID-19, I’ve never seen so many people die in one shift, day after day.
You have to put up a kind of wall to help you, but at the same time, this has become extremely overwhelming, mentally, for healthcare workers, including the city EMS.
Paramedics give medication, start IVs, intubate. What has really changed after we do all that, and we do CPR and there has been no change in the patient, is we have the grim duty of declaring the person dead at home. We had a gentleman recently who had been sick, COVID-19 positive for two weeks. He wanted to stay home and refused to let his family call 911. Finally, the day came: He was short of breath — he could barely breathe. His family called 911. We got there, he stopped breathing. He had lost his pulse. We worked on him feverishly. He did not survive and he died in the back of our ambulance. This gentleman was probably about 70, with a very close-knit Latino family. We had about 20 people surround the ambulance because they knew we were working on their family member. I had the responsibility to tell them we did our best, but that he had died. At that moment, I realized because this person died in my ambulance, the next step for this family, for this patient, was going to be the city morgue. This was going to be the last time that family was going to see that person for another two weeks, if that. They were distraught.
There’s a very human aspect to this, what they called the “invisible enemy.” But it’s not very invisible when you deal with it on a regular basis. As appeared in New York Daily News on April 29, 2020.
U.S. Picks Worst Possible Moment to Cut Funding to WHO Padmini Murthy, M.D., M.P.H., M.S.
Cutting funding will make U.S. vulnerable to COVID-19 The interconnectivity of the world has never been more evident than at present as illustrated by the COVID crisis. As a professor, often I have told my graduate students in public health that we need a passport and visa for travel but not a disease as it can cross geographic boundaries easily and often undetected. This fact has been highlighted by the recent global onslaught of pandemics in the past decade. The roles of public health entities such as the World Health Organization (WHO), Centers for Disease Control (CDC), and Pan American Health Organization (PAHO) are crucial as they serve as guardians of the health of global communities. It is no exaggeration to refer to them as sentinels during pandemics. The member states of the United Nations since the formation of the World Health Conference have funded the activities of UN agencies including the WHO. On a personal note, I have the honor of representing my NGO as a focal point at the World Health Organization, I have had the opportunity and privilege of working with colleagues in the WHO on maternal and child health, including women’s health. A working partnership between the WHO and health NGOs in official relations with the WHO are crucial in advancing the health of global communities and even more so during global pandemics such as the current COVID crisis.
their country offices, and their local partners to promote the targets specific to United Nation’s Sustainable Development Goal 3 “ Ensure Healthy Lives and Promote Wellbeing For all at All Ages.” On Tuesday April 14th, the announcement that the United States would cut funding to the World Health Organization has provoked mixed global reactions especially as the number of people affected by the coronavirus is at an all time high of 2 million cases. This decision to withdraw funding pending a review of the actions and role of the organization in addressing the pandemic could not come at a worse time. This cut in funding results in a substantial blow to the WHO as in 2018- 2019 the United States contributed $400 million out of the 6-billion-dollar budget to the WHO and was the largest donor providing 15% of the annual budget. The WHO has been playing a crucial role since its inception in April 1948, providing support, assistance and advice to low and mid income countries on crucial public health issues and challenges faced. In my opinion, the United States puts itself in a vulnerable position by cutting funding to the WHO. It will be more challenging to address this global catastrophe, which will have both a direct and an indirect causal effect on the U.S. economy and societal well-being. It is no exaggeration to say that the World Health Organization has been at the forefront in addressing global pandemics by being an important partner in the GOARN – ( Global Outbreak and Response Network) and by providing the necessary technical expertise and skills on the ground where and when they are needed most. WHO has been at the focal point in coordination of multidisciplinary efforts by proving human and technical resources to facilitate rapid identification and timely response to international outbreaks. The COVID pandemic is a global fire and continues to burn unabated. We are all vulnerable to the effects of this burning inferno, and the member states of the United Nations, including the USA, need to be enabling the World Health Organization in its crucial role as first responder rather than imposing monetary sanctions. As appeared in AMWA on April 28, 2020.
I have attended the annual World Health Assembly in Geneva at the WHO headquarters and have to come to learn firsthand the work done by WHO headquarters,
We Need a Better CARES Package for the Elderly Ira J. Bedzow, Ph.D. Mark Goldfeder
Photo Credit: UPI Photo
In February and early March, the nation watched as COVID-19 swept through Life Care Center, a nursing home that became the early epicenter of the outbreak in Washington state. One home, 35 deaths, 129 infections. This was enough for the Centers for Disease Control and Prevention (CDC) to release special guidelines about containment of the virus in skilled nursing facilities. Since then, however, Congress and state governments have done little to ensure that the most vulnerable among us — the elderly — have the supplies and the support that they need. The number of deaths in nursing homes is surging, and more than 3,800 residents are reported to have died from the pandemic. Unlike in other nations, this is not because of any “triage” decision, where resources are intentionally allocated to younger populations for the sake of getting a better return on investment. In our country, the elderly’s exposure to COVID-19 is related to lack of governmental oversight, which can and should be easily corrected. The health care provision of the Coronavirus Aid, Relief, and Economic Security (CARES) Act was designed to protect patients in health care facilities. So far, attention — and allocation of funding — has been going primarily to hospitals, which obviously need resources so that medical professionals don’t have to decide who gets treated and who dies. But it is equally obvious that we need to make sure the elderly don’t end up in those hospitals in the first place. The 2.5 million elderly Americans in long-term care facilities are most susceptible to high mortality risks from COVID-19, since with age comes many co-morbidities that decrease the survivability of elderly coronavirus patients. Long-term care providers are facing immediate and dire circumstances, as supplies run low and staffs dwindle, but the current guidance under the CARES Act is unclear as to how they actually might receive funding to ameliorate the situation. As it stands, estimates project there could be as many as 87,000 deaths among the elderly if drastic action isn’t taken immediately.
More than 2,500 homes across the country have reported cases. The risk to the elderly is not a consequence of negligent medical staff. Skilled nursing facilities and assisted living communities have made unprecedented investments in response to this crisis, expenses that are directly tied to providing an appropriate response to the threat of the pandemic. Physical distancing, for example, is less effective in places such as nursing homes, because people simply live closer together, and so devoted staff have to be more vigilant to keep contagion at bay. Without additional staffing and other resources, such as personal protective equipment for medical professionals and extra essential daily supplies for residents, it will be difficult to protect people from exposure or contain the virus if a resident gets sick. The result is that these homes and communities face an unsustainable operational and financial burden. Adding insult to injury, aside from the Health and Human Services (HHS) portion designed to reimburse medical facilities for coronavirus-related expenses, the CARES Act contains provisions to protect American employees and small businesses, but nursing homes and long-term care facilities are also precluded from this aspect of the legislation. Under the CARES Act, the Paycheck Protection Program is available to any small business with fewer than 500 employees, which would seem to apply to many nursing and care facilities. However, the Small Business Administration’s (SBA) “affiliation rules” dictate that when determining whether an applicant is eligible for a loan, the administration looks at not only actual employees of the nursing home or care facility but also employees of affiliate facilities. This negatively impacts many, if not most, nursing homes and care facilities, which, although separate and independent entities for the most part, often operate in the franchise model. Congress explicitly excluded other franchises from these limitations, such as hotels, restaurants and bars. The same exception should apply to our front line, life-saving employees at nursing homes and long-term care facilities. In short, nursing and long-term care facilities should be eligible for assistance under both the HHS Health Care Provision of the CARES Act, which distributes needed money to health care facilities, and the SBA Payroll Protection Program, which allows small businesses to get loans. Currently, these facilities cannot benefit from either provision. This must be rectified. Financial assistance is essential for the safety of residents in many of these homes, which face an immediate crisis from the lack of health care workers and essential supplies. Americans who began their lives with the Great Depression and World War II should not have to fear for their lives today. As appeared in The Hill on April 18, 2020.
Weighing the Economics, Public Health Benefits of Sheltering in Place Ira J. Bedzow, Ph.D. Adam E. Block, Ph.D.
Imagine trying to hold your breath. Some of us can hold it only for a few moments, others for a bit longer. Now imagine trying to hold your breath as someone starts taking the air out of your lungs. The impulse to breathe becomes much stronger. This is what is happening all over the country as we feel the effects of “sheltering in place.” We sit at home watching the stock market fall and companies lay off employees or put them on furlough. We all want social distancing to end and for life to go back to normal. However, the consequences of emerging from our homes too soon will be catastrophic for everyone. It will affect young and old, fit and frail, in terms of both health and wallet. Over the past several weeks, many Republicans have framed the debate in terms of saving people from economic threats to life, while Democrats framed it in terms of saving people from pathogenic threat. Despite the debates in Congress and on political talk shows, when to end social distancing is not simply a matter of either public health or the economy. Our leaders need to recognize the consequences of both sheltering in place and opening up for business. They must then make decisions that reduce the negative effects of each choice and maximize the benefits of both. Public health and economics are aligned in this case. There is no recent precedent for what is happening, so we have limited evidence. However, economists at MIT and the New York Federal Reserve Bank found that, after the 1918 flu pandemic, cities that instituted social distancing earlier and more aggressively fared better economically. They also found that less social distancing led to higher flu mortality and lower economic activity. Given our current ability to engage in virtual meetings and shift our transactional activity online, we should expect fewer negative economic impacts per extra day of social distancing.
public health and an economic strategy to stop the long-term effects of the spread of COVID-19. This may be difficult to imagine in areas where the pandemic so far has had little impact, but if we wait until COVID-19 is on the rise in these places, it will be too late. If we open up for business too early, we will not get the economic improvement we all desperately desire. Even in places where contagion may be in check, without mass testing and home isolation for those who test positive, fear of a second wave will limit economic improvement. Just because a restaurant or store is open doesn’t mean that people will want to eat there or be willing to risk their health to work there. If contagion is not held in check, the virus will rip through the country, leaving any market that we still have without either supply or demand. There will be few consumers willing to risk getting sick to buy goods and few workers willing to go into the market to produce their goods. Any state or federal investment in recovery will have been wasted. As the virus continues to spread across the country, working its way from the predominantly Democratic coasts and major metro areas into the predominantly Republican heartland, we must be careful not to make rushed decisions. Opening up for business too soon would be like telling people it’s safe to go back to work on the middle floors of the building as the bottom and top floors are still aflame. Sheltering in place—even as it starts to really hurt—is still the better option in terms of both public health and economic well-being. When we do finally open for business there will be more pent-up demand and more confidence in the restarted economy. We will also have greater faith in our government, especially if it continues to pass legislation that helps the people weather the pandemic. The cost of an extra few weeks of sheltering in place is primarily financial—painful and stressful, but curable. This does not trivialize the complications households and small businesses are facing. It recognizes that the government is still well-equipped to handle crises that can be solved with money. However, once a pandemic spreads without control, the government cannot stop it. And as Italy has seen and New York City is on the verge of experiencing, once we run out of hospital beds and clinical staff, it is very hard to create more. Public policy is where our economic and social values meet the practicalities of our daily life. We need a plan to get back to the lives we once lived. But, if we tell our citizens to take that breath too soon and they continue to contract COVID-19, then no ventilator will be able to help our country. As appeared in Modern Healthcare on April 6, 2020.
Social distancing should therefore be seen as both a
Too Little or Too Late: U.S. Senate Response to Public Health Crises Adam E. Block, Ph.D. Kevin van Dyke, M.P.P. Adaeze Enekwechi
Africa. By the end of August 2014, there were 3,707 cases and 1,808 deaths, including five Americans who wrote a paper on Ebola’s genomic surveillance. The Senate HELP Committee addressed the disease within a month of the first case in the United States and held a total of two hearing on Ebola. Two years later, in January 2016, the first case of Zika was found in the United States. The Senate HELP Committee held its first hearing on the disease on February 24, 2016. Still, the country witnessed more than 5,000 cases during that year, but less than 100 in 2017.
Photo Credit: Brendan Smialowski, AFP
In a few short weeks, COVID-19 has changed the way we live, travel, work, and interact with each other human beings both in the United States and around the world. But it was only on March 3, when the crisis was well underway with six deaths and 100 confirmed cases in the U.S., that the Senate Health Education Labor and Pensions Committee (HELP) held hearings with experts to understand better the crisis and how to prepare legislative solutions. In its classic deliberating way, the Senate was scheduled to have another hearing on March 18, when the U.S. had 150 deaths and 9,003 infected. By that time, the pandemic had advanced so rapidly that everyone in Washington, D.C. and millions around the country were told to stay home to mitigate the spread. This is telling of the ability of the Senate to act quickly and decisively to improve the nation’s public health. While COVID-19 is new, the potential for a severe, highly transmissible virus that would overwhelm the health care system and require an immediate and drastic response has been known by experts for decades. As the nation continues to mobilize to fight this pandemic, it is useful for policymakers, health care providers, payers, business leaders, and society as whole to take a step back and look at the last decade through the lens of how policymakers in Washington and the Senate have addressed public health crises.
Too Little In addition to ongoing work to improve the treatment of chronic illnesses such as heart disease and diabetes, there have been several new public health issues in the last decade. In January 2014, an Ebola outbreak emerged in West
Overall, the responses to Ebola, Zika, and COVID-19 were relatively quick by congressional standards, occurring within two months of each outbreak. However, the coronavirus’ impact is so large, and the response has been slow, limited, and largely economically focused meaning it has led to inadequate prevention and public health interventions. This has left the public health system dealing with shortages of staff, precautions, tests, and treatments without the help of legislation. Although relatively timely, this public health response was too little to have an impact on the largest global pandemic in a century. Beyond infectious disease outbreaks, there are two other new public health epidemics where the Senate responded years too late: opioids and vaping.
Too Late The opioid epidemic accelerated in the last decade before peaking in 2017: from 18,515 deaths in 2007 to 47,600 deaths in 2017, an increase of over 250 percent. The first hearings in 2012 were devoted to prescription drug abuse. In total, there were five hearings in the five years between 2013 and 2017, too little focus at the time. And then, in the year after opioid overdose deaths peaked, hearings in the Senate spiked to eight. E-cigarette use or vaping has been increasing exponentially, growing by 900 percent from 2011 to 2015. In teenagers, usage increased from 11 percent in 2017 to 25 percent in 2019. But only in November 2019, after 68 confirmed deaths and nearly a decade of exponential growth in the industry, there was a single Senate hearing to discuss the impact of vaping on health. A smoker is engulfed by vapours as he smokes an electronic vaping machine during lunch time in central London on August 9, 2017.
Although vaping and opioid abuse now receive substantial attention, legislative focus, and resources, the legislative response occurred only after these issues became a nationwide crisis. The response was too late to make any real change in the epidemicâ&#x20AC;&#x2122;s trajectory. In the last ten years, hearings in the Senate related to public health prevention and containment have been largely reactive and trailing the media rather than the leading edge. The Senate has been slow in response once there is a crisis, and has not worked to prevent them. With access to the worldâ&#x20AC;&#x2122;s best experts and the legislative power to mitigate public health disasters, the Senate should be leading instead of following. As appeared in The Globe Post on April 3, 2020.
RACE, ETHNICITY, GENDER AND SOCIAL DETERMINANTS IN THE TIME OF COVID 526
Higher Education’s Misguided Obsession with Diversity Officers Julio A. Rodriguez-Rentas, M.A. Ali Jackson-Jolley, M.B.A.
America’s higher education institutions have a consistent response to addressing race scandals— they throw a diversity hire at the problem. In the face of mounting racial tension, or in the event of a discrimination reproach, college and university leaders look to carve out space at their leadership table for chief diversity officers. But as nationwide protests and race riots bubbled up in response to the gruesome killing of George Floyd, exposing the vicious cycle of racist and deadly force at the hands of law enforcement, our nation’s top higher education leaders awoke to the stark realization that they too had failed to do their part in addressing systemic racism. From the annals of academia, the response was swift. A decisive call for societal change was needed. Though diversity officers have proven to be ineffective forces of change, more than a month later, they are still universities’ modus operandi. The verdict is still out as to whether anything will improve for black college students and students of color.
Growing Number of Diversity Officers Rapidly growing in numbers, diversity officers are put into place to support marginalized populations, including students who identify as Black, Indigenous and people of color (BIPOC). This creates more diverse, inclusive and equitable environments that benefit the entire college community. According to the National Bureau of Economic Research, nearly two-thirds of all U.S. higher education institutions now have a diversity officer on staff—30 percent of these positions were created in the past five years. Yet, despite the trend toward hiring diversity officers, institutions have seen little change. For example, a recent study by the Hispanic Journal of Law and Policy found that U.S. colleges have not seen substantial growth in racial diversity among faculty members over the past decade. This is particularly jarring at research institutions where the number of
Black tenured faculty grew by one-tenth of a percent during that time. Similarly, the number of Latinx and Hispanic faculty members grew by less than 1 percent. We fully recognize one of the daunting hurdles in the way of improved faculty diversity is the dearth of BIPOC doctoral degree holders—particularly in the areas of math, science and research. Still, this woefully low representation of BIPOC Ph.D. candidates (which is being addressed at the K-12, undergraduate and graduate levels) is not the entire problem. To add a layer of complexity to the issue, among the colleges and universities without a diversity officer, university presidents have suddenly been bombarded with impassioned cries of “we need one, we need one now!” But in the shadow of the COVID-19 pandemic (and subsequent economic downturn and budget hardships), the calls for change have been answered with, “Although important, we simply don’t have the resources.” Herein lies the problem. The solution for real systemic change cannot be bought with a single salary. It cannot rest with one person. When universities fail to make change under the pretext of not having the funds or a diverse pool of candidates from which they can hire diverse staff members, they are blind to the fact that money is not the only solution.
Diversity Is Not a One-Person Job We are not arguing that having no diversity officer is better than having one. To be clear, the problem does not lie with the diversity officer. Rather the problem is with the unreasonable expectations placed on one executive. Unfortunately, no matter how much some may tend to think it doesn’t exist, racial-ethnic bias and equity issues are as American as apple pie—they are ingrained into the very fiber of American identity. Have we made progress as a nation? Yes. Have community colleges and public higher education institutions made some major gains in this area? Yes. But what about the social disparities that do not help BIPOC succeed? Do we all just sit back and say think, “that is bad,” but then do nothing about it? It is naive at best, disingenuous at worst, to rely on a diversity officer to single-handedly unravel centuries of bias culture. Creating an inclusive environment, facilitating multicultural content in curricula and campus programming, attracting and hiring a diverse staff, and recruiting a diverse student body is not a one-person job. The diversity officer is a bandage, a quick fix to assuage BIPOC students, faculty and staff. But over time, often, the diversity officer becomes the scapegoat: ill equipped and under supported, ultimately set up to fail at enacting the change necessary to move the needle. To truly address the enduring issue of systemic inequity, everyone across the university community needs to take ownership of the problem.
A social media post by influencer and entrepreneur Brandi Riley read, “Thank you for your Black Lives Matter graphic. May I please see a picture of your executive leadership team and company board?” Higher education institutions, whether due to accreditation bodies or social pressure, all highlight the diversity of their campuses in admissions marketing collateral, but only look at the student body. What about the diversity of a university executive suite? Rather than one diversity officer, it is more important to have people of color across the boardroom, the classroom and the faculty. Part of the solution is to look at practices across an institution. It doesn’t cost money to assess one’s behavior, looking at the empirical data and making the necessary adjustments. For example, in recruiting, higher education institutions often use outdated methods, like classifieds in print newspapers, which result in non-diverse hiring pools. It is time to cast a wider net, using more targeted channels—websites, social media, and digital and print publications with a readership among the BIPOC community. By assessing where and how to recruit, we can improve our diversity without necessarily increasing our costs.
The Time Is Now In a recent letter to the Columbia University Teachers College community, President Thomas R. Bailey, Ph.D., wrote, “The battlefront isn’t simply a protest, march or petition, it can also be a classroom, or a community health clinic, or a food cooperative, a clinical trial, a standardized test design. Wherever we find ourselves at work, or in any interaction, that can be the place where we make change happen.” Everyone can do something. All of us are the change. We have a responsibility. We can all do something wherever we are. It is our job to go beyond the niceties and affect meaningful change. To quote noted inclusion strategist and thought leader Vern Myers, “Diversity is being invited to the party. Inclusion is being asked to dance.” As appeared in HRPS on August 13, 2020.
A Pandemic in a Pandemic: Gender Based Violence and COVID Padmini Murthy, M.D., M.P.H., M.S. Vikas Grover, Ph.D., CCC-SLP Aishu Narasimhadevara, M.A.
this silent pandemic . For example, countries such as Kenya and Trinidad and Tobago are making use of technology in their judiciary to address the issue of GBV. Pharmacies and supermarkets in France and Spain are a part of a safety network and have put into place emergency warning systems to provide counseling services to victims of GBV and assist with reporting abuse during the current crisis. In another move, almost 20,000 hotel rooms across France have been designated as safe spaces. The Police department in an Indian state called Odisha is using telephone services to reach out to those women who lodged complaints about abuse pre-COVID crisis.
Role Played by UN Agencies
“If we are to fight discrimination and injustice against women we must start from the home for if a woman cannot be safe in her own house then she cannot be expected to feel safe anywhere.” — Aysha Taryam
A Snapshot of the Situation As the COVID -19 crisis rages, the impact on women and girls has been devastating. It includes rising rates of domestic or intimate partner violence and forced marriages. The lockdowns and social distancing have taken their toll on survivors of gender-based violence (GBV). They become more isolated, with few avenues to turn to for help, and many of them may be financially dependent on their abusers as a result of being unemployed. Unfortunately, as many of us are aware, these lockdowns in personal spaces such as homes are far from being safe havens. Research by the United Nations Population Fund (UNFPA) indicates at least 15 million more cases of domestic violence around the world in 2020 for every three months that lockdowns are extended. It is no exaggeration to refer to this silent pandemic of GBV as “A Pandemic within A Pandemic.” Globally, women and girls are in the fight of their lives, trying to survive the pandemic of COVID and the violence they are subjected to daily. It is alarming to note that prevalence of domestic violence has increased by 25% in many countries and this increase has been attributed to the various shelter in place policies which have been instituted since the past 3 months. Survivors of GBV, especially those behind closed doors, are facing a third challenge of not having access to the support they need including legal services and social protection. The pandemic has resulted in a shortage of both monetary and human resources across many sectors as they are being diverted to strengthen public health measures needed to address COVID-19.
Global Strategies to Address the Silent Pandemic A recently released UN Women report mentions the various strategies put into place globally for addressing
The United Nations Development Program (UNDP) in Somalia has partnered with local communities to implement neighborhood watch initiatives in local communities and to make them alert to any incidents of GBV in their area. Similarly, in Mexico, UNDP, is working with another UN agency, namely UN Women, to use phones and online platforms to support vulnerable women via the LUNA centers, which have been created as safe spaces for women and girls. In the Dominican Republic, UNDP and BHD Bank recently created a partnership to facilitate referral services of domestic violence cases that are reported by the bank’s customers. This is a great illustration of public-private partnership in addressing the silent pandemic of GBV. In addition, UNDP is coordinating with other UN sister agencies, development partners, and governments on The Spotlight Initiative, a joint EU-UN partnership to end violence against women and girls. This global, multi-year initiative aims to assist 50 million direct beneficiaries across five regions and more than 25 countries.
Recommendations Increasing partnerships between UN agencies, academia, and civil societies to address GBV is vital. Using the various social media platforms to spread advocacy and awareness about the silent pandemic of GBV will also create a channel for abused women and girls to seek assistance and support. We have to use timely and effective communication (Handbook for Coordinating GBV in Emergencies) to address this severe societal problem. Effective communication strategies foster a positive and trusting environment for the victims as well as for the workers. By sharing information about it and providing a safe platform for the victims, we can slowly create a long-term solution. It is crucial that we come together as a united global community to pool our resources to tackle COVID-19 and gender-based violence. As appeared in AMWA on July 24, 2020.
Let Ageism Bite the Dust During COVID — Don’t take the statistics to mean that all seniors are compromised
Angela Rossetti, M.B.E., M.B.A.
65 population was the first to go into lockdown in California. On the other side of the country, in re-opening Connecticut, those over the age of 65 are advised to “stay home and safe” and out of hair salons. In either locale, the “disappearing” neighbor or the “shaggy-haired” are revealing their age and society’s perception of them. California Gov. Gavin Newsom and Connecticut Gov. Ned Lamont used appropriate data and caution in their efforts to protect the vulnerable. But sociologically speaking, seniors’ early disappearance from society and now unkempt re-emergence are telltale signs of the belief that all seniors are compromised.
COVID-19 has exposed many deadly fissures in American healthcare. From inadequate personal protective equipment and unavailable testing to the more heinous differentials in deaths based on race, many cracks in American preparedness and response have glaringly emerged.
In 2005, CMAJ published what has now become known as “the Frailty Index.” This index ranks the health risk of seniors based on their biologic fitness. The Index uses a scale of 1-7 to rate the health of the elderly, with the first cohort described as robust, active, energetic, and fit for their age and the last, near terminal.
Among these and other deeply disturbing facts is the disproportionate toll that COVID-19 has taken on the elderly. The CDC reports that during the week of April 18, 2020, the current peak of American deaths, COVID-19 claimed nearly 13,000 deaths in people over 65. A more recent report, spanning Feb. 12 to May 18, indicated that 75%-80% of all COVID-related deaths were in this age group.
The Frailty Index has been in widespread use in Canada for a decade and a half. Perhaps it is time that American healthcare took a look at it, too. Although there are many horrible COVID-19 deaths among the elderly, there are many, many examples of biologically fit seniors in our midst, from National Institute of Allergy and Infectious Diseases Director Anthony Fauci, MD, 79, fighting the pandemic, to New York Gov. Andrew Cuomo, 62, making the hard decisions for his state.
With numbers like these, it is easy to conclude that COVID-19 is a disease of the elderly. But a deeper look at the numbers tells a more complex story. Only 7% of deaths listed COVID-19 as the only cause of death. On average, in each case there were 2.5 additional co-morbidities that contributed to death. Unfortunately, it is the elderly who are more often saddled with co-morbidities that predispose to a fatal course of COVID-19, but the elderly are not alone. Chronic respiratory disease, cardiovascular conditions, and malignancies affect younger cohorts of Americans as well as those over 65. For example, where 30% of current smokers over 65 have COPD, 25.8% of those ages 55-64 do, and 17.1% of those 45-54 do as well. However, because of the higher frequency of comorbid conditions in the elderly, governments have had to make hard choices. As of March 17, the over-
One size does not fit all in healthcare. There are fit individuals 65 and older without pre-existing conditions, and younger individuals sadly compromised by any number of diseases. As with other statistical measures, getting under the numbers and looking at all the facts may help one more “ism” -- ageism -disappear. It is time for this often-overlooked “ism” to bite the dust, not the population it describes. As appeared in Medpage Today on July 14, 2020.
Unspoken and Undone: Caring for Women Dealing with the Emotional Trauma of COVID-19 Angela Rossetti, M.B.E., M.B.A. Lorraine Marchand Cecily Tyler
In late April, a female physician, the Clinical Director of an emergency room at a New York hospital who had treated hundreds of COVID-19 patients, took her own life. On the pandemic front lines, she was a medical survivor of the virus. What she could not survive was the emotional trauma, an often unaddressed side effect of the pandemic. Women make up 80% of all healthcare workers according the American Medical Association. They are physicians, nurses, phlebotomists, x-ray technicians, housekeepers, and many others who perform vital functions to care for the suffering. Many of these women are also simultaneously serving as educators to their children, personal chefs to their families, physical education coordinators for their household, amateur psychologists, and so many other roles that were handled by other professionals, pre-pandemic. All of these women are vulnerable to overwhelming stress. Some healthcare workers, pushed to the brink at work and at home, may be at serious risk for depression, anxiety and the sentiment that they can no longer cope.
Healthcare professionals may face an additional risk: moral injury. The rationing of respirators and staff to treat seriously ill patients, and worse, watching many of those patients die, may have lasting consequences on physicians, nurses, therapists and others. This effect, similar to that seen in soldiers who have witnessed death due to brutality or powerlessness created in times of war, can take a serious toll all healthcare workers, not just women. But women who are already juggling multiple caregiving roles outside of medicine, may be at risk of suffering disproportionately. Beyond healthcare workers, all women without financial resources, sufficient emotional support or adequate time to care for their own physical and spiritual needs suffer. For a woman who is unemployed and financially insecure, the stress of this pandemic may be particularly dangerous. She may be a single parent or married and caring for a war-injured husband, or a newly laid off immigrant housekeeper with a language barrier and no back up plan. She may be a woman forced to live with an abusive partner because there is nowhere else to go. Womenâ&#x20AC;&#x201D;health professionals or notâ&#x20AC;&#x201D;may now be forced to make morally challenging decisions that may harm them: risking their marriages or their jobs because they choose caregiving or living in fear for their own well-being in order to shelter a child. CV-19 is making it imperative that the stresses long specific to women are recognized and addressed. Putting oneâ&#x20AC;&#x2122;s own life at risk for the sake of others is necessary, ultimately noble, but can be insidiously dangerous. As a society, we can better support the women who support us. Actively listen to women, seek to be a consistent source of comfort, guide them to external resources. Helping women stay healthy and safe helps us all. As appeared in Healthcare Business Today on June 12, 2020.
On April 10, JAMA Psychiatry warned of the increased risk of suicide in the time of CV-19, calling the risk a perfect storm of economic, psychosocial and healthassociated risk factors. On May 27, JAMA Psychiatry issued an imperative for psychiatrists to act now.
The COVID-19 Pandemic is Squeezing Women Out of Science Marina K. Holz, Ph.D.
In the early days of working from home during the pandemic, before everyone discovered virtual backgrounds, I noticed something peculiar. My male coworkers joined meetings from bookshelf-lined offices, while my female colleagues logged in from kitchen tables and living rooms. “My husband and I are both professionals who work from home, yet somehow, he is holed up in the upstairs office, while — as you can see — I am here in the dining room,” one of my co-workers remarked during a recent video conference. In the past two decades, we have achieved remarkable gains in equalizing the standing of women in science. The numbers of women as lead authors on research papers and recipients of major research grants, in the senior ranks of the tenured professoriate, and in academic leadership have been on the rise. I am one of these success stories, being the first female dean at my institution, one of many to come. There is still much progress to be made, but we started 2020 with great hopes for the new decade. The pandemic abruptly caused research laboratories to shutter, and working from home became the new normal for most academics. “Great, we will finally have the time to write all the papers we always wanted,” the scientists hopefully proclaimed. But startling posts shared on social media by journal editors suggest that the share of papers submitted by female scientists has dropped significantly during the past two months. The professional slide for women in science has started to emerge. While many male scientists, unencumbered by their usual travel and other distractions, have hit their productivity peak, a disproportionate number of women have experienced a productivity deficit — women overwhelmingly picking up the household responsibilities associated with caring for children and aging parents under the dictate to shelter in place. Women scientists were surprised how swiftly this happened to highly educated, self-aware professionals
who have long advocated for equity in science but fell into the all-consuming role of the caregiver in their own homes. To be clear, many of us acknowledge that our wonderful spouses, who have been supportive of our careers, shouldering the burdens along the way, did not exactly force us into this domestic role. It just happened that they took over the home office and shut the door. Institutions across the nation gradually are reopening their research programs, and scientists with schoolage children are scrambling to come up with child care solutions, as daycares and summer camps will not return to business as usual this summer. Running a backyard child care operation while managing a lab is not an option. Hiring a nanny on a graduate student stipend or a postdoc salary is impossible. Scientists are notoriously nomadic as they progress from grad school to postdoc and faculty positions, leaving them without a local network of reliable family and friends. It is clear that the majority of the child care burden will fall on the female heads of household, who will remain at home while their male colleagues return to their offices and labs reenergized. Summer, one of the most productive seasons for scientists, effectively is canceled for many women in science. It truly would be revealing to see the gender breakdown of grant applications to the National Institutes of Health (the primary federal funder of research) submitted for the June and July deadlines. The adverse effects on female scientists’ productivity — fewer papers, fewer grants —likely will have long-lasting and wide-ranging consequences. Papers and grants are the main currency for competitive fellowships, tenure-track appointments, promotions and awards, the lack of which will affect women scientists disproportionately. While men return to the active practice of science in all of its glorious forms, a large fraction of women will not, perhaps permanently. Whether or not academic institutions and research funders urgently address this issue now will determine the professional futures of women in science for decades to come. As appeared in ASBMBToday on June 5, 2020.
When There Is Diversity Without Inclusion Ira J. Bedzow, Ph.D.
mistrust replace the rule of law. They also reinforce the idea that fear and mistrust may be warranted–at least for those who feel outside the law’s protection.
Photo Credit: Getty Images
If there is one thing that Americans can agree on today, it is that people are angry. The cause of the anger is different for everyone, but the common thread that holds the ire together–even when the ire itself tears society apart–is the senseless death. The deaths are senseless in both meanings of the term. They are without purpose, and they are leaving us all incapable of recognizing the pain that Americans feel. In the past three months, over 100,000 people have died from COVID-19. The majority of these people come from either vulnerable populations, people who are deemed “past their prime,” minorities, or people of lower socio-economic means. Each of these groups can be identified as being outside the standard deviation of society’s bell curve for the “average” American. These are not simply individual tragedies to be mourned. This is a national loss, which has shown how reactive thinking and prioritizing short-term efficiencies over long-term sustainability disallows public preparation for uncertainties. It also shows that the greatest burden of this strategy is placed on those least equipped to handle it. The past three months have also shown us senseless deaths that are not related to the pandemic. Steven Taylor was shot and killed in a Walmart. Ahmaud Arbery was shot and killed while jogging. George Floyd was literally kneeled on to death. These are just three names among many. In every city that has seen protests and violence throughout this past week, other names are included and serve as cries for recognition. When names become symbols, they lose denotation to the persons who carried them. They begin to serve a collective need to replace the needs of the individual lives that were lost. Whichever name is used to recall a senseless death, these incidents show the danger that results when fear and
One may argue that these are all isolated incidents and do not represent a systemic weakness or a quality control issue. However, in private industries that utilize risk analysis and risk management, such as engineering, healthcare, and security, these types of errors are viewed as cumulative act effects, or systemic failures that are not simply caused by human error. When errors occur, leaders and managers engage in a “Swiss cheese model” of analysis that investigates whether the accident can be traced to organizational influences, supervision, or preconditions. The analysis allows for a better understanding of how the act occurred and a more efficient systems-based strategy to prevent it in the future. Think of the initiative that Starbucks established after an employee in one store called 911, claiming that two black men were trespassing. Not only did the manager leave the company; the company’s 175,000 employees had to participate in day long training so that a similar incident would not occur again. Yet, it does not seem that anyone truly feels protected by the rulers who make the law. Shelter-in-place orders are causing protesters to ignore social distancing and to gather in anger in state capitols. The economic and mental health toll of sheltering in place has not been mitigated in a way that allays the concerns of those who see these orders as a threat to their livelihoods and quality of life. Because of the deep-seeded distrust people have in the authority of their leaders, health guidelines and public health related policies are being construed as attempts at political maneuvering to control the populace. Even financial relief legislation has become viewed as a way to bolster the wealthy’s economic and political power at the expense of small business owners, akin to the creation of the “New Russians” who made their fortunes during Russia’s frenzied transition to a market economy in the 1990s. The government’s hold on the economy and on society has become the modern, metaphorical Bastille prison in Paris, the symbol of the French dictatorial monarchy. It seems only a matter of time, if it has not happened already, that the status quo will be attacked by an angry and aggressive mob that seeks revolution and overthrow of the old regime to be replaced by the disenfranchised–a moniker now claimed by every group on the political spectrum. In the U.S. version, however, the mob declares, “Life, Liberty, and the Pursuit of Happiness,” rather than
the French, “Liberty, Equality, and Fraternity.” It is not that the American ethos does not value the idea that all people are created equal or that we should join in common purpose. These values seem to have become– at this present time–simply too far out of reach or too much to ask for. When life itself seems at risk, let alone one’s pursuit to live life as he or she deems fit, it is hard for people to even imagine values that demand people to see each other as equals and in common relation. The anger of the current moment, however, did not arise from the experience of the past three months. The social, economic, and public health crisis was simply the pressure cooker that allowed it to cook much faster than it would have otherwise. This fire of discontent has been stoked for years, and the cooking has been uneven, burning different parts at different times. Just as the anger of the current moment has been simmering for years, it will not subside in a moment– even if the news outlets change headlines quickly. The fire of discontent will not dissipate by shifting direction or by creating distraction. Anger like this needs to be let out. The pressure is just too great to think that it can be held without release. Yet, it need not be destructive. Fire is only dangerous when it is uncontrolled. The person who tends his or her own fire well can use it to melt the hardest of metals to be fashioned as tools. When people are angry, more important than providing solutions is providing an outlet for people to be heard. Not only for people to speak–as important as the voice that cries bitterly are the ears that are inclined to hear it. We must create a way for individuals to encounter each other. We can no longer live alone, side by side. Good fences do not make good neighbors. It is not enough to read other people’s tweets or learn about others through books or diversity training. We need to hear other people’s voices, see their faces. And not the collective others, individuals. Listening does not demand agreeing or conforming to a compromised middle–it means being open to the idea that another person lives differently but lives nonetheless. This idea should not be a threat to the listener or his or her life choices, but an affirmation that choices are possible. “Life, Liberty, and the Pursuit of Happiness” is not one size fits all motto, and when we recognize that, we might also be ready to call for equality and fraternity as well. As appeared in Forbes on June 1, 2020.
Human Rights and Social Inequity Issues are Magnified by COVID-19 Padmini Murthy, M.D., M.P.H., M.S.
The Universal Declaration of Human Rights is considered a powerful document at present, more than 70 years after it was adopted by the United Nations General Assembly at its 3rd session on December 10, 1948, in Paris, France. Since its creation, it is currently available in 360 languages and it is no surprise that it is the most translated document in the world. It is not an exaggeration to refer to it as an acceptable global tool used to measure right and wrong and fight oppression, discrimination and uphold human dignity in communities. I refer in particular to Article 25 of the Universal Declaration of Human Rights, which addresses “the access to medical care, necessary social services and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of lively hood in circumstances beyond his control.” In my role as a non-governmental organization (NGO) leader (both nationally and internationally), representing my health NGOs at the United Nations over the past decade and being actively involved in several international health initiatives— including initiatives on the Ebola crisis in Africa—I believe the response globally to the COVID-19 pandemic has failed to address human rights for many people. Shaking the very core of our existence on planet earth, this health crisis has further highlighted the glaring gaps in access to health care and prevalence of social inequalities, which are creating barriers in addressing the crisis. A specific example is the lack of personal protective equipment (PPE), globally in countries for the first responders (i.e., health care providers), essential workers in various settings who are without an exaggeration are in the fight of their lives while helping their fellow citizens. This is, in my opinion, a lack of access as PPE availability is a component of health care access.
As a health care professional, I am sad, angry and puzzled by the apathy shown by policymakers and some elected officials in not heading the genuine and earnest pleas for protection by the first responders while they go about doing their jobs with utmost dedication and serving others before their own health and safety. Isn’t this violation of human rights with specific reference to Article 25 of the document as it compromises their security? On a similar note, I am dismayed to note that the recent statistics about the mortality rates due to COVID-19 in New York are the highest among African Americans, which highlights the persistent socioeconomic inequalities which are raising their ugly heads during the crisis. It is crucial that stakeholders need to work together and without delay on innovative and effective solutions without social exclusion of vulnerable populations and accelerate the response to address this catastrophe caused by COVID-19 on multiple levels. A final example of the global human rights failure in the context of COVID-19: maternal mortality in India. Specifically, women who recently gave birth in a public hospital in Hyderabad after the world’s biggest lockdown in India faced several challenges. Some of these include the lack of food and necessary personal supplies needed as the hospital cafeteria was closed, and their relatives were not allowed inside to bring the necessary supplies, and this led to this sorry state of affairs. Yes, the lockdown measures were enforced, and social distancing enforced to try to reduce the spread of the disease, but unfortunately, there were no mechanisms in place to address the needs of these vulnerable women and their newborn infants. As a woman, I am dismayed and cannot help wondering if men in hospitals would have faced the same challenges faced by these women? I strongly believe this highlights gender discrimination, which is magnified often challenging to address more so during global emergencies caused by war, disease, or natural calamities. As a global citizen, I appeal to my fellow citizens that we need to strategize on how to level the playing field for all groups of the population and work to ensure that the human rights of all are not violated. As appeared in Medpage Today’s KevinMD on April 15, 2020.
ETHICS IN THE TIME OF COVID
A Pandemic Ethical Conundrum: Must Health Care Workers Risk Their Lives to Treat COVID-19 Patients? Alan Kadish, M.D. John Loike, Ph.D.
Photo Credit: Go Nakamura/Getty Images
The sweep of COVID-19 across the globe has raised a fundamental question about medical ethics: Do physicians, nurses, EMTs, and other health care workers have moral and legal obligations to risk their health and lives to treat patients during a pandemic? It’s an important question, given the toll that COVID-19 is taking on medical professionals. As we write this, more than 100,000 health care workers have been infected in the United States alone and nearly 550 have died from COVID-19. The Centers for Disease Control and Prevention estimates that health care workers accounted for 11% to 16% of COVID-19 infections during the first wave. To answer this fundamental question, we first need to define the ethical and legal duties of physicians during a pandemic or a war or a bioterrorist attack — and these aren’t necessarily clear. It is quite revealing that when students graduate from medical school, they all take various oaths modeled on the World Medical Association’s Declaration of Geneva. None of these include any statement that physicians must risk their lives in caring for patients. There are conflicting perspectives on defining the responsibilities of medical professionals during an epidemic. Some have taken the position that medical professionals who refuse to work in hospitals during this pandemic should lose their jobs or even their licenses. This perspective is based on the idea that medicine is a humanitarian profession that requires health care workers to care for the sick under all conditions. By freely entering into this profession, so the thinking goes, physicians and other health care professionals have implicitly agreed to accept all dangers and risks. This view is consistent with that of the General Medical Council in the United Kingdom, which asserts that physicians have an obligation to provide urgent medical care during disasters, even when there is a significant health risk to providing that care.
The American Medical Association takes a different position. Its 2020 update of Opinion 8.3 sets out physicians’ obligations in this pandemic to “provide urgent medical care during disasters … even in the face of greater than usual risk to physicians’ own safety, health or life.” Opinion 8.3 also recognizes that if the risks of providing care to individual patients are too dangerous, then physicians can refrain from treating COVID-19 patients because doing so may hinder their ability to provide care in the future. The American Nurses Association offers similar advice, stating that during pandemics, nurses must decide how much care they can provide while also taking care of themselves. Nurses may refrain from working when they feel physically unsafe due to a lack of personal protective equipment or inadequate testing for infections. Many ethicists believe that physicians and health care professionals may, at times, refuse to care for patients when their service conflicts with their own moral views. For example, physicians do not have to comply with a patient’s wish to terminate a pregnancy, or assist in euthanasia, if that conflicts with their moral framework. These ethicists recognize that emotions and motivations are integral parts of any moral decisionmaking process. There are no rigid rules. Choices must be adapted to the particulars of each given situation. For example, the moral duty not to harm or kill another person includes self-care for the clinician who is providing care to these highly infectious patients. It is akin to not requiring paramedics to enter a building on the verge of collapse to aid someone inside. A health care professional’s specialty may also influence his or her moral obligation to treat a patient or refuse to do so. One who specializes in infectious diseases may not have the moral autonomy to refuse to treat COVID-19 patients, while one whose specialty is ophthalmology, cosmetic surgery, or dermatology can reasonably maintain a moral obligation to serve as a medical consultant or serve in some other capacity in the hospital, but not take on the risks of treating COVID-19 patients. Physicians and other health care professionals must also balance their obligations as professionals with their duties as husbands, wives, parents, and children. The risk to personal health from the coronavirus is alarming enough, but the risk of infecting family members, especially those with a higher risk of infection, may be ethically and morally unacceptable. Health care professionals’ refusal to work in a state of emergency may be justified if their health or well-being is endangered because of medical susceptibilities such as heart problems, diabetes, pregnancy, and the like that place them at a high risk of contracting and dying from the virus, or if they reasonably believe that their work environment creates an unacceptable hazard by
not providing them with essential personal protective equipment. Historical lessons offer insight into this ethical conundrum. For example, the history of secular medical ethics reveals that the medical community has never come to a consensus on the nature and scope of its responsibilities during an epidemic. The lack of consensus may be due in part to the fact that medical ethics are embedded in various broader social and cultural fabrics. Jewish law supports the view that a person is obligated to save another, though there are situations in which the dangers or risks are so high that these moral obligations are not mandatory. Rabbinical scholars have concluded that physicians have an extra obligation to heal the sick and are expected to accept a greater degree of risk than nonphysicians, due to their training and nature of their work. Yet they must also be prudent in their obligation to protect their families. Interestingly, rabbinical scholars maintain that treating COVID-19 patients is not mandatory but is considered to be a great act of compassionate professionalism and is highly praiseworthy. We believe that the question of whether health care workers must risk their lives to treat COVID-19 patients does not have one uniform answer. We do believe that health care workers who specialize in infectious disease or respiratory medicine have a greater responsibility to treat COVID-19 patients than health care workers in other subspecialties of medicine. Moreover, most, but not all, health care workers have a professional obligation to provide some medical service during this pandemic. Society, however, should be understanding of those health care workers who may defer their medical responsibilities because of their own personal health risks or extenuating family responsibilities. While it is important for physicians and other health care workers to explore and come to terms with their moral and legal obligations to care for patients with COVID-19, this will not be our last pandemic. That is why it is essential to incorporate these issues into the medical and health science educational curricula and get students thinking about them early. Professional education should help students â&#x20AC;&#x201D; and practicing health care workers â&#x20AC;&#x201D; learn how to balance their health risks with the immediate benefits to individual patients and the capacity to care for patients in the future. The moral obligation, the courage, the compassion, and even the heroism of millions of clinicians on the front lines are what professionalism is all about. As appeared in STAT on July 24, 2020.
Saving Ourselves From the Groundhog Day Effect Ira J. Bedzow, Ph.D. In the weeks since “sheltering at home” began, we seem to be living in an eternal present. Because our most recent memories of anything different – or “out of the new ordinary” – are weeks old, we have a funny sensation that early March was only a moment ago. There are no experiential memories to track time mentally. Each day feels the same as the previous one to the point where it is difficult to remember if a new day has even begun or not. It is almost as if we have adopted the mindset of Ben Zoma, the young but expert scholar in the Talmud, who sees “all the days of your life” simply as one long day rather than as an expression of a life trajectory over time. This is a dangerous mindset to maintain, and it can cause us to fall into obsessive thinking and feelings of helplessness. It can shrink our perceived range of possibilities as well as our ability to connect with others. In the end, this type of obsessive thinking played a role in Ben Zoma’s mental decline. We should find ways to protect ourselves from allowing the COVID-19 pandemic to similarly take over all of our mental energy. Here are two suggestions to create a break from the repetitive cycle of daily stresses that are brought on by our current situation. Of course, each person should take the details below the suggestions simply as my ideas so that the suggestions themselves speak to you personally, but I will give you my process and experience with them, simply to show how these suggestions could work. Tip #1 – Take a moment every day to reflect on something bigger than the current moment. In order to break the daily repetition, force yourself schedule time to think about something different. Don’t just take this time haphazardly; if you do, you will never actually do it. Establish a moment or two every day that is set aside without distractions. In this time, I ask myself if I still want to become the person I thought I did and whether my actions (both small and large) in this moment demonstrate that desire. Have my values changed, and, if not, am I still acting on them? Am I making room in my life for the people and beliefs that I cherish or am I closing myself off by allowing new – and bad habits – to form? What small thing can I do today to make my life, and the lives of those around me, a bit different? Can I add some fun into the day? Many of us are living with spouses and children, so this may seem impossible, but it is not. My time is early in the morning before everyone in the house wakes up. This works for me for two important reasons. First, it forces me to go to bed at a reasonable hour so that I don’t waste time at night with distractions and waste
time during the day because I am overtired. Second, the scheduled time serves as a way to start my day thoughtfully and with purpose. It makes the upcoming frenzy that I must ultimately face secondary to the main goals and purposes to which I want to dedicate my life. (Truth be told; I actually take a second scheduled time after the work day as a reward for finishing the day, like spraying Febreze after cleaning a room. This time allows me to reset my priorities and my mood before having dinner and spending time with my family.) Whatever time works for you and whatever questions you ask yourself, the important thing is that we expand the ever-narrowing worldview we risk acquiring when our movements and options become limited. The bigger you make the life around you, the less the pandemic’s social and psychological consequences will bear on you. Tip #2 – Take a day each week and make it wholly different from the rest. Days turn into weeks very quickly when there is nothing that marks a beginning and an end. In order to impose a structure on your weeks, as well as give you respite from the daily anxiety onslaught of the current situation, take a day and make it different. We all have heard about taking a “mental health day” which is specifically meant to relieve stress and prevent burnout. In normal times, 40% of workers in the U.S. say they find their jobs stressful; just imagine what the percentage is today. Mental health days are not simply days off. They are meant to help clear and heal a person’s mind so that he or she can return to work more relaxed and productive. In order to use a day to reset your perspective, you need to change what you do, how you talk, and even what you think about on that day. The importance of making a day separate and distinct is proclaimed by the prophet Isaiah, who emphasizes that one “restrain from your normal goings for the sake of the Sabbath, from pursuing your affairs on My holy day; and call the Sabbath a delight, the Lord’s holy day honored,” by not continuing our usual daily activities or even speaking in our usual ways. While the prophet demands that the Jewish people engage in distinguishing the Sabbath day for the sake of honoring God, there is no doubt that making such distinctions benefits the Sabbath observer as well. As Achad Ha’am famously said: “More than Jews have kept the Sabbath, the Sabbath has kept the Jews.” Both of these suggestions share the same idea. We need to find ways to hold onto the bigger picture before losing sight of it due to the overload of the everyday. Happiness is elusive even in times of relative calm, and when you aim for it directly you always miss the mark. “It is the very pursuit of happiness that thwarts happiness,” says Viktor Frankl. However, if you search for meaning and purpose, and take steps every day to reinforce your values, happiness may just come along for the ride. As appeared in The Times of Israel on May 2, 2020.
When the Current Crisis Passes, Will We All Still be Created Equal? Ira J. Bedzow, Ph.D. Stacy Gallin, D.M.H.
The arc of our country’s moral universe, bending toward justice, has steadily sought to broaden the practical application of the words of our Declaration of Independence, “that all men are created equal.” Yet discussions regarding triage and allocation of scarce resources in the wake of the COVID-19 pandemic risk changing our national cry to something that is reminiscent of the conclusion of George Orwell’s book, “Animal Farm”: “All animals are equal, but some animals are more equal than others.” As hospitals are writing policies on how to treat what they see as an overwhelming deluge of incoming patients, many are looking to other countries for guidance in how we should allocate scarce resources. Utilizing established best practices is extremely important for crisis management, but we must also make sure that humankind creates guidelines and protocols that are based on our moral arc. Decisions like these, and medical decisions in general, cannot be made on science alone. Treatment and care decisions will always entail applying science and medical facts to the goals and purpose of medicine — healing others. In Italy, the Society of Anesthesia, Analgesia, Intensive Care and Therapy published the paper, “Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments, in Exceptional Resource-Limited Circumstances,” a 15-point document intended to “offer authoritative professional and scientific support to those who are forced by daily events to make sometimes difficult and painful decisions.” The Society guidelines clearly prioritize greater life expectancy as the criteria for access to intensive care and life-sustaining treatment, but they also state that if the situation demands, it may become necessary to set an age limit for ICU admissions and allocation of scarce medical resources. Though the recommendations certainly did not intend for this to be the case, age
quickly became a lightning rod because of COVID-19’s general impact on the elderly population. Looking at age or disabilities — when those factors do not relate to the direct cause of a patient’s prognosis or probability of survival — as a reason for not providing care out of deference to a general guideline is troubling. It embeds an inherent social bias that the elderly or those with disabilities are less equal than others for consideration of medical treatment. Even comorbidities can become reasons for prejudice if not considered in light of their effects on survivability and prognosis. For example, African Americans are 60% more likely to be diagnosed with diabetes than non-Hispanic whites in the United States. People with diabetes face a higher probability of experiencing serious complications from COVID-19. Yet, if a person’s diabetes is well managed, the risk of severe complications from COVID-19 is currently perceived as being the same as the general population. Diabetes, and other comorbidities, however, require long-term care and management, something to which not all members of the population have equal access. Creating these types of clear guidelines that are easy to follow comes at the expense of acting contrary to the professional goal of medicine — serving as healers to the vulnerable. Hospitals must be thinking about creating guidelines to help medical professionals make decisions in the moment. There are a lot of medical factors to consider and, in normal times, it takes a lot for people to weigh the various factors to determine the right course of action. In a pandemic, these decisions must be made quickly with very high stakes. Yet guidelines should not take the place of doctors’ or ethics committees’ roles in making decisions. Individual cases should not be answered simply by deferring to general — and hypothetical — examples. In times of high stress, however, we run the risk of guidelines
doing more than they are meant to do. They can end up becoming definitive rules for making decisions rather than serving as aids to the real decision-makers. Because of this, hospitals must be even more careful to create guidelines that cannot be used to justify bias, prejudice, or priorities in people based on “social usefulness.” We already have examples from other health care crises in history when Do-Not-Resuscitate orders served to declare that a person was not worth saving, regardless of medical prognosis. In the article, “The Deadly Choices at Memorial,” about what happened during Hurricane Katrina, we can read how hospital leadership interpreted DNR orders to mean that those with them had the “least to lose” compared with other patients if calamity struck and these patients would not wish their lives to be saved at the expense of others. It is extremely important to make sure health professionals’ efforts go for the sake of saving lives — as many as they can. And they should recognize when their efforts may be illusory. But saving lives by discounting others right off the bat is not in line with our medical or social ethics, even if it might be utilitarian. Times of disaster do not call upon us to throw out our everyday values and adopt a different form of disaster ethics. Think of the analogy between a regular season game and the Super Bowl. The rules are the same, but the stakes are higher, and the players are more skilled to face the challenge. Similarly, this moment calls on us to rise to the challenge of applying our ethics and making moral decisions when we need to most. Otherwise, after the COVID-19 crisis has passed, we may find ourselves facing an even bigger threat to society — and our humanity. As appeared in The Citizens’ Voice on April 11, 2020.
What Happens When We Run Out of Ventilators? Jewish Law and State Guidelines May Have Different Answers Ira J. Bedzow, Ph.D.
Photo Credit: Getty Images
The COVID-19 pandemic facing this city will test our country’s most deeply cherished values: respect for multiculturalism and religious freedom on the one side and the state’s responsibility to promote the common good on the other. This inherent tension is quite literally an issue of life and death. In New York City and elsewhere, hospitals are close to experiencing a shortage of personal protective equipment and ventilators, which will greatly tax the hospital system’s ability to provide care. To be clear, as of now the city’s hospitals have not run out of ventilators. Yet given the rise in the number of patients coming to the hospital each day, preparation is warranted. As hospitals develop triage protocols to prepare themselves for the time when they will need to treat too many patients with not enough medical resources, rabbis and public religious figures are grappling with the halachic answers to those same questions. And the protocols that New York City hospitals will ultimately adopt are going to clash with the position held by most, if not all, Orthodox rabbinic authorities. If two patients show up at the hospital at the same time in need of the only ventilator, both hospital guidelines and rabbis assert that physicians should use clinical judgment to determine which patient has a better chance of survival. The problem arises once a patient is already put on a ventilator. Many hospitals look to the 2015 Ventilator Allocation Guidelines, written by the New York State Task Force on Life and the Law, to help them figure out how to ration ventilators. In a crisis, hospitals continually assess patients to determine whether they should stay on a ventilator or should be removed so that someone else can have
a chance to live. The 2015 guidelines recommend that after being placed on a ventilator, patients must be reassessed after 120 hours, and every 48 hours thereafter, to see if there has been an improvement in their overall health. If there hasn’t been, the patient should be removed from the ventilator so it can be given to another person with a better chance of survival. The details of the guidelines’ recommendations would not apply in the case of COVID-19, since patients typically must be on ventilators for a week or two before they show signs of improvement. Therefore, any new guidelines that emerge will necessarily have longer timelines before recommending reassessment. But the overall idea of periodically seeing if a patient should continue on a ventilator or be removed for the sake of saving another person will be adopted in the new guidelines. The normative Orthodox position in such a situation is far different: Once placed on a ventilator, a patient cannot be taken off unless the condition improves or the patient passes away — even if someone else with a higher chance of survival will be deprived of a ventilator as a result. This position is grounded in the idea that “one life should not be pushed aside for another.” In the Mishneh Torah, Maimonides writes that in a situation where a group of Jewish people is being accosted by idolaters who threaten them by saying, “Give us one of you and we will kill him. If you don’t, we will kill all of you,” they should all be killed rather than hand over a Jewish life. In essence, halachically, it is better to allow many to die than to actively participate in killing a single person. The majority of contemporary American Orthodox rabbis rely on the rulings of Rabbi Moshe Feinstein to provide practical guidance in the case of triage. When Feinstein was asked about triage in the early 1980s, he wrote (Igrot Moshe, Hoshen Mishpat 2:7375) that if a patient is already being treated, even if physicians incorrectly judged his or her survivability and mistakenly allocated resources to his care, another person with higher chances of survival does not take precedence and resources should not be re-allocated. Feinstein’s reasoning is as follows: There is no obligation for one patient to surrender his life for the sake of another. Therefore, when the patient was allocated medical resources, the resources in effect became the patient’s for as long as the individual maintained life. It is not the case that medical resources are given to the patient contingently by the hospital until the hospital decides to take them away for the sake of another person. Rather, the resources have been committed to the patient as long as they
are keeping him alive, without contingency. This is the case even if the second person is in a life-threatening condition and could be saved if given the resources. As you can see, the difference is clear — hospitals will re-evaluate and reallocate resources in hopes of maximizing the number of people they can save. The Orthodox position places a primary value on stopping any type of active killing. The religious mandate is to endeavor to save lives, not to think that we have ultimate power to decide who lives and who doesn’t. As New York City hospitals have not yet reached capacity, this clash of values has stayed in the realm of the theoretical. However, we already are beginning to see how even the idea that hospitals will not follow Jewish law is causing great worry in the Jewish community. Maimonides Medical Center, located in the heavily Jewish Borough Park section of Brooklyn, is following the concerns of the Orthodox community: The hospital has committed to intubate patients and work with local religious leaders to provide patients the care they need based on their religious beliefs for as long as they can. However, Gov. Andrew Cuomo has pushed to have all of the city’s hospitals work as one system, which will include a set of common guidelines when there may not be enough medical resources to go around. If, God forbid, we get to a point where triage protocols must be followed, the state will choose the common good over respect for religious freedom. This calculation is embedded in the Western concept of liberty from the outset, as expressed by John Stuart Mill in his essay “On Liberty.” “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others,” Mill wrote. This would not even be the first case in New York in the past 12 months where public health trumped religious freedom. Last April, Mayor Bill de Blasio signed an executive order compelling residents to receive the MMR vaccine due to a measles outbreak. Though this may not be the first case where the state is faced with choosing the common good over the rights of individuals, it certainly is the most devastating. It’s tragic not only because hospitals may not have enough resources to care for its patient population, but also because our country must push aside the values of tolerance and religious freedom for another set of priorities. As appeared in Jewish Telegraphic Agency on April 2, 2020.
The Ethical Minefield of Prioritizing Health Care for Some with COVID-19
Hospital ethics committees around the country are looking for guidance to a few recent policy models, advanced in medical journals and in public discussions, regarding the allocation of resources during the pandemic.
Ira J. Bedzow, Ph.D. Lila Kagedan, M.Ed.
However, many of these example policies rely on two dubious assumptions. First, they make a distinction between public health ethics and clinical ethics and frame these decisions in terms of public health. This distinction is meant to focus on the welfare of the general population rather than those individual patients toward whom physicians have a fiduciary responsibility. This then justifies making decisions based on “the greatest good for the greatest number” even if certain individuals may suffer from it.
“We are at war with a virus that threatens to tear us apart,” the World Health Organization Director-General, Tedros Adhanom Ghebreyesus, told world leaders in a virtual summit on the coronavirus pandemic Thursday. Such dramatic phrasing as “the war against COVID-19” and “physicians are on the front lines of battle” is heard everywhere today -- in the media, and from politicians and health care workers around the globe. As US hospitals grapple with the influx of infected patients, this war analogy is creating a morally problematic way of thinking about how to allocate resources to the critically ill. In a war, we want to treat and return the strongest and fiercest soldiers to the battlefield to kill the enemy. In a pandemic that is straining medical resources and health care systems, we want something different: to save civilians’ lives in a way that maintains our own humanity. Ethicists use the term “triage” to explain how onthe-ground decisions about health care are decided in a medical emergency. While “triage” has become an accepted medical term, its roots in wartime practice has the potential to influence who should get treatment for COVID-19 based on factors that are not strictly clinical. This influence does not apply when there are resources -- even if limited -- to be had, but rather when critical capacity is overwhelmed and decisions must be made about how to treat too many people with too few resources. We do not fight a disease in the same way that we fight an enemy during wartime. We should therefore be making decisions based on concerns that are clinically relevant to survival. And we should not be making utilitarian decisions that make assumptions about who would remain, and compose the best society, after the pandemic is over.
The mistake of this type of thinking is that it frames these triage decisions incorrectly: as matters of public health. Medical professionals in the hospital serve a clinical role and should be making clinical decisions. Public health policies are about prevention of disease and utilize overarching community strategies such as “shelter at home.” They are not meant to deal with individual treatment decisions -- even if there are many -- that need to be made in the moment. Moreover, even if one were to apply public health ethics here, the fundamental values of clinical ethics would still apply -- just on a larger scale. As such, we cannot simply throw out values, such as equity and social justice, because they are harder to maintain in a triage environment. Second, not only are these ethicists’ example policies for resource allocation utilitarian in the sense of saving the most lives, they would also create policies that prioritize saving the most “life-years.” Saving the most “life-years” does not mean that those with the highest chance of survival from COVID-19 would get treated first. It means that, between two people with somewhat equal chances of survival, those perceived to have the most years left to live would get greater consideration. The moral justification for this prioritization is that it gives younger people the opportunity to live through life stages that they have yet to reach. While some ethicists try to explain that this choice does not consider intrinsic worth or social utility, it is very hard not to see this as a way of saying “Well, older people, you have had a good run. Let’s let the younger people have a chance to get old now as well.” There are other ways to respond to the challenge of choosing between cases of equal mortality, such as “first come, first served” or lottery selection. Of course, in the case of COVID-19, age is often clinically relevant,
since with age comes other physiological factors or conditions that will affect chances for survival. But we should be fully aware of when we are considering a clinical factor and when we are submitting a patient to social bias. We understand the motivation to be utilitarian and to want to maximize “life-years” -- it makes the rules clear and it is easy to feel that “life is good, so more life is better.” But clarity alone does not make for good morality. Prioritizing “life-years” solely for the sake of giving the youth a chance to get old is as much a non-clinical social decision as any other that we should try to avoid. Potential quantity should not be deemed actual. We may assume a younger person will live longer, but one can never be sure that this will be so. We should not be utilitarian based on assumptions that are outside the clinically relevant. Ethics committees and medical professionals have no moral authority to presume the value of “life-years” or who will give a greater contribution to society when the pandemic is over. Guidelines for ethical allocation of resources should stick to considerations of chances for overall survival from COVID-19. Indirect factors, such as age, disability, and comorbidity (existing physiological conditions that make a patient more vulnerable), should only be considered as they relate to prognosis and survivability. It will seldom if ever be the case that all considerations for resource allocation for two COVID-19 patients will be exactly equal. And if there is a case where it is close, we shouldn’t simply defer to general guidelines that turn decision makers into soldiers on the front lines. As appeared in CNN on April 1, 2020.
INNOVATION AND ADAPTIVE LEADERSHIP IN THE TIME OF COVID 546
The COVID-19 Vaccine is Coming. But Will We Be Ready? Alan Kadish, M.D.
Photo Credit: USA Today
As the COVID pandemic continues to spread around the world, progress on vaccine development has been encouraging. Although it is premature to declare victory, three vaccines are now entering large-scale clinical trials. They all work in different ways, providing some hope that one or more will prove effective. While there have been some missteps in handling the coronavirus, the efforts to fast track vaccine development of different types, although not yet successful, have largely gone well. It is no surprise that many people are cheering this news. A potential vaccine in development at this pace was inconceivable a few short months ago. With luck, a vaccine will be ready for wide-scale use in about a year, a dramatic improvement over the typical time frame of 10 to 15 years for most vaccines. The next question is, “who will be vaccinated?” Indeed, one would expect that the biggest issue is that too many people want to rush to be protected. Shockingly, polls show otherwise. In some, half of Americans say they are skeptical about the safety of a coronavirus vaccine and may refuse to take it. This is more than surprising; it is dangerous. The best way to stop this pandemic is by administering a vaccine to the large majority of people. While there are those who have resisted taking vaccines in the past, the risk/benefit ratio for a potential coronavirus vaccine is different. Coronavirus is highly infectious and, in many cases, highly lethal, particularly to vulnerable members of society such as the elderly, disadvantaged and malnourished. The case for preventing the spread of the coronavirus, even if it involves some modest risks, could not be clearer. Along with the continued breakneck-paced scientific research, we need a massive public education program to encourage vaccination. Once a vaccine is developed, we need to ensure that everyone who is potentially a
candidate gets immunized. This will require massive education, advertising and engaging role models for the elderly and other vulnerable communities. This public education campaign needs to start now, while we still have time. As a first step, we must understand why so many people are saying that they will not agree to be vaccinated. I can make some educated guesses based on data from other anti-vaccine movements. Some have long-standing religious objections to many advanced medical therapies, but they represent only a tiny fraction of those who object to vaccination. Past health care discrimination has led to skepticism about traditional medicine in some minority communities. The history of unequal treatment is real and disturbing. It must be addressed so that it does not lead to widespread death and disease. Conspiracy theorists who have come to dominate segments of social media pose the greatest danger. Conspiracy theories about vaccines have helped lead to resistance to measles vaccines and the resurgence of measles in the United States. When COVID-19 first appeared, the World Health Organization warned of an “infodemic” of misinformation. We need to stop this infodemic in its tracks to stop the pandemic. All medical treatments have some side effects — that should not deter us from clear-headed risk benefit analysis. Vaccines are not a plot by some cabal. Pharmaceutical companies do not by and large make large profits from low-cost vaccines. We have the expertise to launch such a campaign. The Centers for Disease Control is investing in educational campaigns to make people more aware of the dangers of prescription opioids and to help people prevent Type 2 diabetes, to name just two. Regardless of which of the vaccines is released commercially, some side effects will be present. Some people may even become ill. But we know the devastation that the unchecked COVID-19 pandemic can cause. We have to individually, communally and as members of the world community take the risks needed if vaccines are shown in largescale trials to be safe and effective. Refusing the vaccine not only puts individuals and their family at risk, but it violates the compact that ought to hold us all together as human beings. We can’t fail again. As appeared in LoHud on August 12, 2020.
How Tech Is Saving Lives During COVID Padmini Murthy, M.D., M.P.H., M.S. Nayanesh Bhandutia, M.S., M.B.A.
custom-made hands-free common door handles to reduce the transmission of the coronavirus from inanimate objects, which are a common source of infection.
Smartphone Tracking: High-Tech Contact Tracing Using technology to track cellphone users has been used in countries like Singapore and South Korea for contact tracing. Bluetooth and wireless signals to trace users in proximity have been used in Singapore. On the other hand, South Koreaâ&#x20AC;&#x2122;s success in containing and managing the outbreak was due in part to tracking phone use, in addition to bank transactions and use of closed-circuit television footage. As the COVID-19 pandemic relentlessly spreads globally it has been pushing healthcare systems to their limits and compelling governments and healthcare institutions to rethink their service delivery strategies. While the number of men infected by COVID-19 is greater than the number of women, globally girls and women face challenges as gender inequality has become more pronounced and womenâ&#x20AC;&#x2122;s health status has been affected. Member States, United Nations agencies, non-government organizations, and foundations are incorporating the use of technology to address this grave public health crisis.
It was interesting to note that Moscow launched a QR-based system to track the disease in the country. The U.S.-based tech giants such as Apple and Google launched a partnership in April 2020 to roll out a Test and Trace strategy.
Shift to Telehealth Many safety-net clinics in the United States are using telehealth services as much as possible. According to a survey of health centers by the Health Resources and Services Administration in April, by the end of 2020 about 54% of health center visits were conducted virtually.
COVID-19 is the first pandemic in human history where technology and social media are being used on a massive scale to keep people safe, productive, and connected while being physically apart.
Planned Parenthood has announced that it will offer telehealth services in all states in the United States, including contraceptive counseling and other sexual and reproductive services.
Among the current innovations are the following:
Also in April 2020, the World Health Organization and the International Telecommunication Union with support from UNICEF announced a plan to partner with telecommunication companies to text people directly on their mobile phones with vital health messaging to help protect them from COVID-19. The aim is to leverage cellphone technology to connect with people who lack access to internet technology. The program is expected to launch initially in the Asia-Pacific region.
3D Printing In Spain, to address the shortages for personal protective equipment, coronavirus makers and tech companies open-sourced their designs for making masks and ventilators to assist patients with mild symptoms of COVID-19. Other companies made use of printers to print components to modify snorkeling masks into ventilator masks. In Italy, The FabLab, a start-up company, launched a project that printed 3D valves, which were used to connect respirators to oxygen masks to meet the shortages in the supply chain of these valves. Formlabs, which partners with technology companies in the U.S., has started printing 3D nasopharyngeal swabs, which are needed to collect samples for COVID-19 testing. Materialise, another tech company, has allowed free access to its designs for use with 3D printers to make
Maternal Health According to the World Health Organization, approximately 810 women died in 2017 from preventable causes related to pregnancy and childbirth. This rate could very well rise during the pandemic due to restrictions on movements and shelter-in-place orders. It is of utmost importance that pregnant women who cannot visit service providers regularly receive information related to their health.
Smartphones have been playing a crucial role for expectant women to receive information raising their health literacy, and many mobile apps have either been launched or revamped to cater to this growing audience. Going forward, such apps may become a regular part of the healthcare system providing reliable and certified health information. Women in developing countries, where smartphones are a luxury, receive such information through SMS or use of Unstructured Supplementary Service Data (USSD) protocol to communicate with their service providerâ&#x20AC;&#x2122;s computers via text messages. Various countries, including the United States, are implementing new models, especially in large urban areas, to conduct virtual home visits to address the critical support needs of pregnant women. Midwives in developing countries are also starting to use this mechanism to connect with expectant women using tablets with built-in SIM cards. Some of these models might become part of a wider maternal health system even after the end of the pandemic. Interactive Voice Response has also found an increased use as women can call a number and self-navigate through pre-recorded information before reaching an operator. In a number of southern African countries, the United Nations Population Fund has provided tablets and smart projectors to midwives to promote distance learning. These pre-configured tablets have apps that are preloaded with animated content and health videos. The tablets can also aid virtual or augmented reality-based learning. All these means are presenting opportunities to collect vital personally non-identifiable health information related to maternal health. The volume of information will come in handy as artificial intelligence-driven algorithms are developed to perform predictive analysis of the issues related to maternal health with an ultimate goal of reducing maternal mortality. ....
As appeared in Medpage Today on June 30, 2020.
Amid a Historic Pandemic, Public Health Must Take the Lead Even With Other Concurrent Disasters George W. Contreras, M.E.P., M.P.H., M.S., CEM, FAcEM
As we continue into mid-2020 and several months into this historic COVID-19 pandemic, Memorial Day 2020 marked an important milestone as the death toll in the United States surpassed 100,000 deaths, and many states started to reopen even while cases are still rising in their respective areas. As of June 25th, the United States now has over 2.3 million cases and 122,000 deaths. In the Northeast where the initial wave seems to have passed, New York State is finally experiencing a steady decline in cases and deaths. From a public health perspective, however, a looming threat remains—a resurgence of virus transmission based on recent warmer weather, mass gatherings and more people going back to work causing an increase of people in parks and beaches, some with disregard to physical distancing and wearing face coverings. In light of the lengthy incubation period associated with this virus and the growing disregard for precautionary measures throughout the nation, I am deeply concerned with the real possibility that we may be facing a second peak as part of initial wave in a matter of weeks—jeopardizing the significant progress that we have made in flattening the COVID-19 curve over these past months. There is no easy answer. No quick and painless fix. I acknowledge the almost fifty million people are currently unemployed in the United States, many who are struggling to survive, unsure of what their next day will bring. Will they have enough money to feed their family, pay their rent and other needed expenses? As an assistant professor at the Institute of Public Health in the School of Health Sciences and Practice and assistant director at the Center for Disaster
Medicine at New York Medical College, I am fortunate to be able to remotely continue my duties. As a New York City paramedic, working in the trenches I continue to see the realities of our current situation. From this perspective, I see that, just because the number of cases and deaths are declining so far, it by no means indicates that this pandemic is behind us. Rather from my vantage point, I see that we are clearly still in the middle of this historic pandemic. As a paramedic, it’s impossible to forget that each new COVID-19 case, each additional death is not simply a number. The numbers are real people who are fathers, mothers, brothers, sisters, aunts, uncles, grandparents, sons and daughters. They are healthcare workers and first responders and even colleagues. Above all, they are all human beings who died unexpectedly and too soon. New York City (NYC) contributed to more than fifty percent of New York State’s cases and deaths. The extreme circumstances were so severe, they required: convention centers to be retrofitted and converted into hospitals, refrigerated trucks to serve as temporary hospital morgues, the USNS Comfort to dock in Manhattan, more than 400 out-of-state ambulances and 1,600 personnel who came to assist with emergency medical services (EMS) during its darkest hour. Some may assume that working nearly three decades as a NYC paramedic should have prepared me for what I saw during this pandemic. But it didn’t. Being an EMS instructor and professor of public health and emergency management should have prepared me. But it didn’t. In these past few months, I have witnessed so many people die during a single shift, week after week. It was certainly an eye-opening and disheartening experience. It reminded me how important it was to keep the human aspect even during these unchartered times because each death that gets reported or published is a human being and someone’s loved one. As of today all regions in New York State have reopened in a staggered manner which allows for close monitoring of established indicators. Some regions are even set to enter Phase 4 by this June 26th. After being closed since March 23, New York State Governor Andrew M. Cuomo rang the opening bell at the New York Stock Exchange on May 26 to emphasize that we are moving towards a new normal. New York City started Phase 1 on June 8th, entered Phase 2 on June 22nd and Mayor DeBlasio announced today that NYC is on track to open by July 6th. With the recent tragedy involving the deaths of George Floyd and Rayshard Brooks and the subsequent national protests, I am even more concerned about a resurgence of COVID-19. I worry about the shortterm consequences of these protests which consisted of hundreds (sometimes thousands) of people, many
without face coverings, gathering in small areas. The long-term consequences can be even more daunting as additional people may die from COVID-19 infection. Mass gatherings are definitely one venue that can promote virus transmission. During the protests and other mass gatherings it is clearly hard to maintain the six-foot distance, especially when the numbers were large and encounters became confrontational. I also worry about the possible increase of cases in the context of the recent Centers for Disease Control and Prevention (CDC) report, which stated that 35 percent of infectious people may be asymptomatic but still infectious. Compounded to this is that fact that COVID-19 has disproportionately affected minority communities. These protests are creating mass gatherings which can present ideal situations for increased virus transmissions. As we reopen many more cities, we need to continue our vigilance and follow established guidelines and public health strategies which will work only if you actually implement them. In the midst of ongoing events, I am not even sure that the public realizes that June 1 also marks the official beginning of the hurricane season. Hurricanes do not care if there is a pandemic or if communities are engaging in protests. The landfall of a hurricane during these times will only make matters worse. These weeks should serve to remind us that we need to all do our part to keep this pandemic at bay. We cannot lower our guard now or become complacent. We stand to lose too much. Even in the face of national turmoil, in the midst of economic distress and potential natural disaster, we must not forget that we are still in the middle of pandemic that currently has no treatment and no vaccine. During these times, frequent hand washing or using sanitizer, wearing a face covering, keeping a physical distance and avoiding mass gatherings must continue. It would be an absolute shame to see an increase in cases due to recent infections who can then transmit to other vulnerable populations. As a result, the governors of New York, New Jersey and Connecticut recently announced that starting June 25th, anyone traveling from eight states (North and South Carolina, Florida, Alabama, Arizona, Arkansas, Utah and Texas) that are current hotspots will be subject to a 14-day quarantine. The progress made up to this point can be easily lost unless we make an effort to keep the public health above water and not overwhelm the healthcare system as the ultimate goal. We all need to continue to do our individual part in order to achieve a collective good for the public. As appeared in Healthcare Business Today on June 23, 2020.
Donâ&#x20AC;&#x2122;t Disparage the Pace of COVID-19 Research Salomon Amar, D.D.S., Ph.D. John Loike, Ph.D.
While scientific misinformation from social media and from high-profile published papers has spread like wildfire in these past four months, there has also been an astoundingly rapid dissemination of validated scientific research published since the first case of COVID-19 was reported. Under normal conditions, scientific research is meant to be a slow, peer-reviewed, and calculated process of developing and testing a hypothesis, reporting the answers, and, finally, waiting for the scientific community to corroborate or disprove the findings. We are experiencing unprecedented times, and the scientific community has stepped up to address this pandemic. There are many critical research milestones that have been either achieved or in active development and reported in thousands of papers published about the coronavirus pandemic. These include: 1) deciphering the genetic code of the virus and how it infects cells; 2) developing accurate assays to detect the virus in people; 3) developing accurate assays to measure the level of antibody titers that should protect individuals from infections; 4) testing treatments and cures; and 5) conducting clinical trials of vaccines. In an incredibly short time, scientists at research universities and biotech companies have achieved remarkable successes regarding the first three milestones and have made impressive achievements in the latter two milestones that will hopefully lead to cures and vaccines. Despite the parallel dissemination of scientific misinformation, this progress is still a testament to the machinery of science and the passion of scientists. Comparing the timelines of COVID-19 accomplishments to those of previous RNA virus pandemics highlights just how rapidly research has moved. For example, acquired immune deficiency syndrome (AIDS) was a term first used by the US Center for Disease Control on September 24, 1982, almost 18 months after the first cited report (June 5, 1981) of five AIDS patients. And it wasnâ&#x20AC;&#x2122;t until 1984â&#x20AC;&#x201D;almost four
years after the first case—when Pasteur Institute and National Institutes of Health scientists independently reported the discovery of a retrovirus (HIV) that caused AIDS. Two years after that, the US Food and Drug Administration (FDA) licensed the first commercial blood test to detect HIV. A year later, in March 1987, the FDA approved the first anti-retroviral drug for AIDS, zidovudine (AZT), in a record 20 months. Finally, the first clinical trial for a vaccine began in August 1987, and VaxGen launched the large-scale trial in 1998. These clinical trials failed, leading this now-merged company (Diadexus Inc.) to bankruptcy in 2016. To date, there are only a few ongoing clinical vaccine studies, but no FDA-approved HIV vaccines. By comparison, scientific milestones were significantly accelerated in response to the SARS epidemic of 2003. On November 16, 2002, the first case of atypical pneumonia, probably caused by the SARS-CoV virus, was reported in southern China. Less than five months later, the US Centers for Disease Control and Prevention published the genetic sequence of SARS-CoV. By May and December 2003, two articles the New England Journal of Medicine described the application of realtime reverse transcriptase PCR (RT-PCR) to accurately detect SARS-CoV in human blood or tissue. Real-time RT-PCR is a very fast and precise method to amplify viral RNA that quantifies viral particles in human biological samples (that is, blood or a nasal swab), and it is extensively used in the COVID-19 pandemic. Still, the response to the SARS outbreak did not deliver the milestones we’ve seen in just a few short months with COVID-19. Currently, there is no medication that is known to effectively treat SARS. Treatment is only supportive. In part because the SARS pandemic subsided with a few years, there are no listed clinical trials for SARS and no FDA-approved vaccine for this virus. The rapid progress to achieve scientific milestones is being seen in real time with COVID-19. On Dec 31, 2019, China reported a cluster of cases of pneumonia in people at Wuhan, Hubei Province that later become known as SARS-CoV-2. Less than two weeks later, on January 12, the first genomic characterization of the virus was reported. Across the globe scientists quickly launched trials to examine the potential efficacy of treatments in randomized or open-label clinical trials. The FDA issued its first emergency use authorization (EUA) of a real time RT-PCR diagnostic test in early February. There are now scores of RT-PCR assays with
high accuracy and few false-positives with other human coronaviruses or common respiratory pathogens. The FDA issued the an EUA to Abbott for an assay to detect antibodies against this virus in March, and now lists more than a dozen serology tests given EUA. Vaccine development for COVID-19 has been similarly rapid and robust, with dozens of companies and collaborators developing and trialing both conventional and innovative technologies. Traditional methods include designing a vaccine with an inactive or attenuated virus that will not infect the recipient but trains the immune system to prevent viral infectivity. New technologies include one that introduces a messenger RNA into an individual so that it can direct cells to make critical COVID-19 viral proteins that are viewed by the immune system as “foreign” and enable the body to build effective immunity. This approach, used by Moderna in partnership with the National Institute of Allergy and Infectious Diseases (NIAID), has not been used in any approved vaccines to date. On May 22, 2020, NIAID Director Anthony Fauci said it’s still possible that a coronavirus vaccine using classical or innovative technologies will be available in the US by December. There are now more than 100 potential vaccines in clinical trials running at an unprecedented pace. The rapid pace of publishing scientific preprints and peer-reviewed articles during this pandemic is bound to result in some mistakes from inaccurate data or poor analyses, but this casualty is worth it in light of the astonishing progress that has been made and will continue to be made in the face of this global threat. History has shown that the scientific community takes full advantage of peer review, collaborations, confirmatory studies from other scientists, and selfassessment to correct scientific mistakes. The rapid pace of scientific research in its ongoing search for truth is not perfect, but the accelerated response has great merit and potential to be used for current and future pandemics. As appeared in The Scientist on June 22, 2020.
The COVID-19 Pandemic: For-Profit Health Plans Win, Hospitals Lose Adam E. Block, Ph.D. Kevin van Dyke, M.P.P. Leah Dillard
As a result, we have seen 1Q20 net income of four publicly- traded hospital systems dropped, an average decline of 11%, and these are the hospitals most able to handle the financial strain expected in the second quarter. The financial performance of other hospitals is following a consistent pattern. Beckerâ&#x20AC;&#x2122;s Hospital Review reported in April that in one hospital Oregon, discharges dropped 40% to 70% and 191 hospitals are furloughing workers., Some hospitals are already experiencing very real fiscal problems and are considering extreme options in spite of being in the middle of a pandemic.
Where is the revenue going?
On April 27, 2020, the Supreme Court of the United States handed down an 8-1 decision granting health insurers $13 billion owed by the Federal government in risk corridor payments, a commitment made as a part of the ACA and then later defunded. On top of this ruling, the preliminary evidence shows that we are seeing the first hints of what is likely to be the most profitable year in health plan history. At the same time, hospital earnings are declining. Since preliminary numbers are only through March 2020 and shutdowns were only in full effect in most places by the last week in March, we expect the effects on hospital earnings to be substantially deeper going forward. The average net income of insurers increased by 20% while the hospital net income decreased by 11% on average across the four publicly traded hospital systems.
What is happening to hospital income? In a worldwide pandemic, where hospitals are publicly scrambling for adequate staff, beds and equipment, one would expect hospitals and provider offices who are treating patients to be in good fiscal health. However, the opposite is true. Although in certain hotspots, like Seattle and New York, many of the hospitals are full of patients, all non-acute visits and procedures, including hip replacements, interventional cardiology and even a portion of oncology treatments, are being delayed to minimize risks to patients and staff. The US GDP dropped about 5% in 1Q2020, nearly half of the economic decline was due to reduced national health care utilization.
Hospital foregone revenue is revenue that is not going from health insurers to hospitals. This revenue is accumulating as a huge windfall at health insurers in their fully insured plans (with employers funding self- insured plans retaining reduced spending in these plans) with five health plan showing an average of 20% higher earnings in 1Q20 relative to 1Q19. Health insurers are admitting this, at least to their investors. Humana said during their 1Q20 call on April 29, 2020 that most of their earnings for the entire year would come in the 2nd quarter. Health plans are continuing to collect full monthly premiums, but for most of March and all of April into early May, have very little in nonemergent spending as has been implied in the financial reporting of the large for-profit health insurers.
How are hospitals, health plans, and other stakeholders reacting? A few responses from health plans will likely be that: â&#x20AC;˘
COVID-19 brings in revenue.
While this is true, but COVID-19 peaks in hospitals are short-lived and afterwards, hospitals beds are empty for long periods as elective procedures remain delayed. â&#x20AC;˘
Patient care is being delayed, not cancelled, and there will be pent up demand coming back in later months.
While the magnitude is unclear, Milliman projected a reduction in health care expenditures of $75 billion to $575 billion in 2020 as a result of the pandemic, with commercial insurers seeing a net reduction of $100 billion to $300 billion in nearly all scenarios. Others agree, an article in the New England Journal
of Medicine cited, “a substantial fraction of care that has been ‘deferred’ may never happen in the future, depressing revenue for many months to come.” Therefore in 2020, a large percentage of visits will not occur and health plans keep all of those dollars. •
Health plans are accelerating payments to help shore up hospitals.
Accelerating payments is necessary but insufficient because it is merely an advance on revenue, not new revenue. This is like telling an unpaid intern you’ll double their pay. It has essentially little long-term impact on total revenues for providers or the windfall insurers will be receiving. This is very different than the CARES Act revenue that Medicare is providing directly to hospitals. Instead of distributing windfall profits as dividends to shareholders from the safety of their own home while watching providers who selflessly treat COVID-19 patients at great personal risk also suffer financially, health plans can volunteer to do more to help. A few things health plans can elect to do are: 1.
Provide monthly payments to network providers based on payments from the prior year until revenue.
Subsidize COBRA for the newly unemployed for three months. This will reduce Medicaid expenses, improve customer loyalty and improve physician finances because commercial plans pay better than Medicaid.
Provide a premium refund to fully insured employers based on quarterly earnings in excess of prior year, something mentioned by United CEO during an investor call.
What does this mean going forward? Hospitals are suffering financially; revenue is half of what it normally is for many hospitals and health plans are retaining much of that gap. Health plans will not just give money to providers unless they fear regulatory action. Health plans will not fear regulatory action unless the public knows these plans are quietly profiteering off of the pandemic while America’s lauded health care institutions, reduced the pay of physicians, lay-off nurses, furlough medical assistants, and slash benefits of the medical sanitation staff. As appeared in Healthcare Business Today on May 27, 2020.
Hospital Industry Faces Reckoning: Where Do We Go From Here?
Similarly, while we should search for a cure and vaccine for COVID-19, we should also recognize that these solutions won’t stop another crisis or the next public health threat.
Ira J. Bedzow, Ph.D. Adam S. Herbst, Esq.
Solving Problems Before They Happen For leaders who look “upstream,” the perspective of “returning” to the status quo is a wasted opportunity. Healthcare leaders who choose to measure success by making things not happen rather than effectively responding will profoundly change healthcare delivery and public health initiatives for years to come.
Photo Credit: John Moore, AFP
As the current health and economic crisis continues to unfurl, the United States’ devastating lack of foresight and subsequent inability to respond to and contain COVID-19 has become the enduring story. Whether the U.S. could have seen the pandemic coming is another story, but this much is true: the country was not ready. So where do we go from here? How can healthcare leaders pick up the pieces while they are still falling and move hospitals, fellow professionals, and the country forward? Before doing anything, leaders must make a choice. They can either see the pandemic itself as a problem they must solve, or see the pandemic as a symptom of the problem they choose to solve.
Problem or Symptom of the Problem? Seeing the pandemic as a problem that must be solved turns the disease into the cause for all public health, economic, and social woes. Stopping the disease by curing sick people and vaccinating others will end all of these problems. This choice will cause leaders to tunnel their vision and react with speed and efficiency to stop the spread. The second choice – seeing the pandemic as a symptom of the problem health leaders choose to solve – allows them to recognize that the disease itself was not the cause of our woes. COVID-19 can spread because of the systemic public health, economic, and social weaknesses that made us vulnerable. This choice allows leaders to accept broader and slower progress, but with long-lasting effect. Of course, one treats symptoms as much as one can. We all take the occasional Dayquil along with our antibiotics. But the smart ones don’t only take Dayquil when they should be taking other medicines as well. And the wisest and healthiest among us learn how to take general preventative measures to avoid getting sick as much as possible.
Changes will not simply be a matter of stockpiling more protective gear or medical equipment and waiting to respond to the next crisis. Priority must be on limiting the need for a response by emphasizing how to avoid problems using reimagined infection-control practices, data analytics, technology, and a greater appreciation of the relationship between socio-economic challenges and health risks. “If you wait for things to happen,” sports physician Dr. Marcus Elliott argues, “you can never quite put things back together the way they were before.” Yet, these leaders won’t even think about the way things were before; they will be thinking about how things could be better.
Engaging Patients For any upstream strategy to be successful, health leaders must engage patients. It will not be enough for health professionals and public health officials to commit to systemic change; the public must also buy in. To communicate and collaborate with patient populations, hospital leadership should participate in town halls to learn the patient’s and staff’s preferences and fears. They should encourage patient input to assess, for example, the suitability of telehealth and other virtual options to develop safer, affordable, and accessible care. Such engagement can also expose inefficiencies so that leaders can better match patient needs with hospital resources. What healthcare delivery will look like after the pandemic is not a decision that hospital leaders will make in isolation. The answer will come through collaboration between federal and state governments, providers, and patients. What healthcare leaders can do, however, is to recognize the problem, take ownership of the commitment to solve it, and search for new approaches to make the needed permanent change. As appeared in The Globe Post on May 15, 2020.
COVID-19: In the Race for a Vaccine, Biopharmaceutical Companies Showing Moral Imperative Ira J. Bedzow, Ph.D. Angela Rossetti, M.B.E., M.B.A.
Photo Credit: Mark Vergari/The Journal News
Yaron Hadari, with Shy Therapeutic, works on tissue cultures in his work space at the BioInc@NYMC incubator on Dana Road in Valhalla.
Pressure continues to mount on biopharmaceutical companies to find a vaccine to prevent and a treatment to cure COVID-19. Individuals and governments are putting most — if not all — of their hope on the biopharmaceutical industry to cure them of their viral and economic woes. Only a vaccine will bring us out of future economic peril and a cure will save thousands from death. Unfortunately, nature does not give up its secrets easily. In normal times, development of new pharmaceuticals or even the repurposing of existing ones is a long process. Part of the reason is based on the rigor of the scientific method. It takes time and repeated trials to prove that a drug actually works as intended. The other part is the need for safety. We cannot allow “cures to be worse than the disease itself.” Under all circumstances, biopharmaceuticals must meet these two high bars: safety and efficacy. But there is an added, enormous challenge for biopharmaceutical companies today. With the death toll mounting and economies sputtering, this work must be done at unprecedented speed, all the while encumbered by operational challenges. Scientists cannot easily work remotely. Devoting full staff to drug discovery and development may not be possible, since critical personnel may not be available due to illness. Disruptions in the supply chain may hinder research by being unable to deliver needed research supplies. And lurking just beneath the surface of the challenges of discovery, development, production and distribution, is another hurdle: unrealistic expectations for speed of a cure by the public coupled with long-standing negative public perception of the industry. Bad actors such as Martin Shkreli, who jacked up the price of an old drug by 5,000% and was sentenced to seven years for securities fraud, are not representative of the
industry, despite the fact that his actions secured an enormous amount of inflammatory press. The truth is, fewer and fewer biopharmaceutical companies hold deeply to the Friedman doctrine, the dogma that a corporations’ sole responsibility is to its shareholders (i.e. maximizing returns) and that companies have no social or public responsibility. Those that do, such as Shkreli’s company, tend to be formed for financial gain, not for socially redeeming purposes. Today, more and more companies are balancing the legitimate corporate responsibility for profitable operations with social responsibility. Shareholder interests increasingly coexist with corporate goals to advance public health. The moral stance and social values of a biopharmaceutical company matter to society — and to companies themselves. Examples of this are seen with Gilead’s donation of 1.5 million doses of Ebola drug remdesivir (sufficient for 14,000 courses of treatment), and Regeneron’s submission to the FDA of a triple antibody cocktail for Ebola that may have potential to prevent or treat COVID-19. These drugs may or may not work, but the industry is testing them at a speed never before seen. ACTIV (Accelerating COVID-19 Therapeutic Interventions and Vaccines) is a collaboration of the federal government and the biopharmaceutical industry designed to prioritize vaccine and drug candidates, streamline clinical trials, coordinate regulatory processes and/or leverage existing assets to rapidly respond to the COVID-19 and future pandemics. This is part of the whole-of-government, whole-of-America response the administration has led to beat COVID-19. This collaboration not only benefits society; it benefits the industry as well. Collaboration may help diminish the public’s suspicion of the biopharmaceutical industry’s motives. Under normal circumstances, drug discovery and development may take as long as two decades and cost $1-$2.6 billion. Today’s pace has greatly accelerated: Vaccines that previously took 20 months to go from genetic sequencing to human trials are now taking fewer than five months to accomplish the same progress. BIO, an industry organization of biopharmaceutical companies, reports that as of April 13, nineteen companies are working on vaccines, fourteen companies on therapeutics, and three companies on better diagnostics. Out of both necessity and collaboration, the biopharmaceutical industry is moving forward with new discoveries and new tools to address the devastation of COVID-19. In recognizing the public need of the day, biopharmaceutical companies that rise to the occasion will change public perception of the industry. The public, which has ranked the pharmaceutical industry as one of the least admired American industries, may end up seeing it as the savior of our way of life. As appeared in LoHud on May 4, 2020.
Wake Up Call For Industry Leaders: The Time To Think About COVID-19 As A Complex Adaptive Challenge Is Now Ira J. Bedzow, Ph.D.
Photo Credit: Visionhaus
The COVID-19 pandemic is creating complex adaptive challenges that affect most (if not every) industry sector in the country. Unlike technical challenges, which are easy to identify and can be solved by an authority or expert who affects change in one or two problematic areas, complex adaptive challenges are not as straightforward. These challenges require both a change in organizational perspective to identify the issue and a change in approach across the organization to implement a solution. Don’t get me wrong, businesses and organizations are facing many technical problems as well, such as how to stay afloat in the short term. These challenges are neither easy nor insignificant. Yet potential solutions to these challenges can nevertheless be found using existing resources, problem-solving strategies and protocols. For example, decisions, such as whether companies furlough employees or seek loans to retain them, expand online or delivery services or cut supply for the time being, all make immediate changes while still maintaining the existing overarching modus operandi. If leaders look only to solve these immediate problems without also taking a step back to consider the bigger picture–i.e. which social and financial disruptions are temporary and which will change the state of business– they may stay afloat in the short term only to face existential problems later. The reason the COVID-19 pandemic is creating complex adaptive challenges across industries is due to the pandemic’s effect on both public health and economics. Because a vaccine is realistically 12 to 18 months away, even if social distancing stops the spread of the pandemic by the summer–which at this point is an optimistic goal–our reality will not suddenly snap back to the status quo ante. Just as there are regular measles outbreaks in communities of anti-vaxxers, the country must be on guard against a second wave in the
fall and future outbreaks until most of the population can get immunized. This fear of future outbreaks will change the way consumers shop and suppliers deliver goods. It will also change the way the public regulates social gatherings. The changes will last for so long that returning to the “old way of doing business” will become impossible by virtue of the fact that companies that do not adapt will not survive. And, even if they do, consumers will have become comfortable with the new mode of business and will no longer want to return to the old ways. If you have any doubt this is true, consider how the long-term effects will play out across the real estate and education industries. Even if the particular effects may be different, the challenge is the same for both. The reason I am choosing real estate and education is that the former is primarily a for-profit industry and the latter is primarily not-for-profit.
COVID-19 and the shifting real estate landscape New urbanism is a real estate movement that started in the 1980s but really took off in the early 2000s. It changed the way that real estate companies looked at development, urban planning and municipal land-use strategies. Moving away from suburban sprawl, density became more popular and mixed-use development (which combine multi-family, retail, and office buildings) created spaces where people can live, work and shop. However, real estate companies must now consider how the pandemic will change future development as well as the current real estate landscape going forward. By this I mean that leaders in the industry must predict COVID-19’s ripple effect on the real estate business, long after the pandemic has been quelled. For example, will zoning laws change to require greater public health safety standards? This might include lower density projects or increased costs of construction or renovation, by requiring more complex heating and ventilation systems to purify the air and/or larger common spaces, both of which affect the value of current property holdings. For mixed use projects or retail centers with entertainment as its anchor or shadow anchor, how will the public’s change in demand for previous forms of entertainment create leasing challenges or the need for adaptive reuse? How will changes in leasing of retail and office space affect surrounding apartments or housing located near those properties? Empty shopping malls and office buildings decrease the value of the surrounding property and potentially increases the rate of crime in nearby areas. These types of questions do not yet have clear answers that can be identified let alone solved by making one or two changes in a company’s business model. Leaders need to start thinking broadly and in new ways about the future of their business.
The future of education delivery In education, the pandemic will necessarily change both how curriculum is delivered and what types of offerings will be in demand. Leaders of schools from elementary to graduate school must think about what this means for the upcoming year and onward. Online education will become the norm at universities, not only because large lectures and living on campus will continue to be a public health risk next fall, but also because students will demand online curricula more and more as time goes on. This change will affect the types of training teachers will need and the resources in which schools must invest. It will also create a situation where what was once considered an asset now becomes a liability. For example, New York City campus life–or campus life in other urban centers–may not be worth the premium it once was. Also, many humanities departments which have high social value for a school may now be seen as a financial drain, since philanthropic support for those departments will diminish due to economic decline. Student enrollment will also drop because of the low perceived translatability of degrees in those areas of study to jobs after graduation. Education leaders will need to figure out how to mitigate the financial exposure to these potential liabilities, while still maintaining the mission and values of the school. On the curricular content side, rather than cutting those vulnerable departments, an option may be to transform them from being content-based departments to providers of competency-based curricula. A few colleges around the county have already considered this new model, where the subject matter serves as a means to develop critical thinking skills and ways to apply different methods of analysis. With this change, those departments can transform to explicitly support students’ desire for workforce skills in an economic downturn.
Timing will be everything Whatever the answers will be for industry leaders in many fields, the challenge is the same. Leaders must think not only about how to manage the current crisis, but they must also take a step back to consider what the landscape will look like after the crisis has abated. Leaders shouldn’t rush into completely new business models, but they shouldn’t put their heads in the sand either. Six months is but a breath away in business. A new semester will begin before anyone can even think about how the current one fared. Successful leaders will be the ones who start recognizing that the “new normal” isn’t just a catch phrase. It is a wake up call to change how they see the future of their companies. As appeared in Forbes on April 12, 2020.
LOOKING FORWARD IN THE TIME OF COVID 560
Want More Women in Leadership Roles? Focus on Their Strategy and Not Their Smile Jennifer Riekert, M.B.A. Ali Jackson-Jolley, M.B.A.
Photo Credit: AFP
When playing the centuries-old game of economic strategy, business leaders have often clamored around a truth, best summarized by American economist Milton Friedman — the secret to capitalistic success is learning how to play within the rules of the game. A “game,” wherein the only norms (or “rules”) are engaging in “open and free competition without deception or fraud.” This may be the case for those at the top of America’s societal hierarchy— the wealthy, white men who reigned at boardrooms and political podiums alike, dominating the most powerful positions for most of America’s history. Yet for women, this is not, and has never been, completely true.
Rules of the Game As the COVID-19 pandemic began to squeeze women from the U.S. workforce, so too increased the news media’s scrutiny on the unequal playing field faced by women in the workforce—but long before the pandemic hit, women in the U.S. workforce faced a much more difficult path to the top. Women have long been engaged in a second game; a game quietly played beneath the surface, like a secret handshake to an underground society, wherein an invisible set of rules apply: Be effective yet not too assertive. Pleasant and agreeable without seeming too soft. Remember to be charming so people don’t feel threatened by your ideas or your intelligence. Don’t talk too loud—or too much. Dress in a way that is neither too feminine nor too masculine. Be empathetic but never emotional. And for a woman of color, these rules are even more arcane, and harder to discern. On one hand, a woman of color constantly swims against the widely preconceived notion that — either by dint of genetics or environment — her knowledge and abilities are less than. Yet her success also hinges on being pleasant, articulate, gregarious, and putting everyone at ease in her presence, lest be deemed angry or dispensable.
But above all else, regardless of race, one must always come to the boardroom or the podium wielding her best, most disarming smile. So deeply entrenched, we are in these rules, that we unwittingly become our own gatekeepers. Recently, one of us returned from a photoshoot for an award honoring trailblazing female leaders. The resulting photos showed a commanding businesswoman sitting at a boardroom table, flanked by two male colleagues, clearly and confidently assuming a leadership role. However, the photos engendered an overwhelming fear — “I don’t look warm or likeable enough.” The charming mask often worn by women to make ourselves appear less threatening had slipped and the resulting photos put on full display a powerful businesswoman. The fear of being rejected for overtly looking powerful is something a man would never consider. Even the strongest, most accomplished women leaders can’t escape these cultural expectations. While admired by many for her stoic strength, razor-sharp intellectualism, and unrelenting toughness, just hours into winning the spot as Joe Biden’s running mate, Kamala Harris came under fierce fire. Specifically, news coverage was riddled with sexist attacks about Harris’ lack of “personal charm” and “warmth.”
Spanning Every Industry Unfortunately, Harris is just one of a litany of political casualties. Pummeled with sexist barbs due to perceived lack of likability and warmth, these women -Hillary Clinton, Sarah Palin, Elizabeth Warren, to name a few -- became lost in the public court of opinion. Like a carnival game, this political stage is rigged against the contestant: a moving target they were never really meant to hit. For these women, striking the perfect balance of being assertive without being “bossy” has become more important than their intelligence, professional achievements -- even their policy. Across every arena, women at the top of their industry have found that to be successful in today’s America means being smart and extremely effective —but never so overtly as to bruise an ego. Just ask the likes of famously fierce former CEO of Hewlett-Packard, Carly Fiorina, fashion mogul Victoria Beckham, and sports icon Serena Williams how often they have been found lacking in the media for their disturbing lack of a ladylike smile.
Dissolving the Game As we look to a near future, in which the COVID-19 pandemic will most assuredly continue to hit women in the workforce the hardest—there should be no doubt that now is the time to dissolve this game and strip ourselves of the subtle yet deeply ingrained rules that govern the game.
Generation COVID: From the Eye of the Storm, a New Generation is Born To fully tap into the potential of women’s strength, we must first endeavor to change the way we speak, worrying less about deliverance and more about the content of our words. This means being unfiltered, speaking without apology, refusing to allow others to speak over us. Perhaps even changing our speech patterns— rather than softening our voices we must speak with a tone of authority. This new approach boils down to a simple rule we as women need to remember: being likeable is not our sole mission. While it must be each woman’s goal to unapologetically toss aside this archaic rulebook that guides what it means to be a successful female leader, it is not just women who need to change. We must shift our culture, starting with how we raise our children. For example, rather than solely emphasizing obedience, cooperation, and supportiveness, society must encourage girls to share their opinions, take risks, assume leadership roles, solve problems —and praise them when they do so. If we want more female leaders, we need to vote for them, support their business and shine the light on female role models who are unapologetically using their voices to drive change.
The most important culture shift is also the simplest. We must all shift to hear what women have to say. Listen instead of scrutinize. Allow women to express their ideas, in whatever way we choose regardless of how we look or the delivery of our words. When we are able to support women based on our ability to lead, our vision, and our strategy rather than our perceived pleasing demeanor— then we can all smile. As appeared in The Globe Post on September 18, 2020.
Ira J. Bedzow, Ph.D. Ali Jackson-Jolley, M.B.A.
Photo Credit: Devon H. via Unsplash
In a hurricane, life is very different depending on which side of the eyewall you’re situated. Just outside the eye, life is fast and perilous. Here, nothing is clear, since the world is moving too fast – and in circles. On the other side of the wall, in the midst of the eye, there is respite from the chaos, an eerie sense of safety and quiet where nothing moves. The stillness of world makes it seem like life is holding its breath until the violence returns to dole out another thrashing. In this time of the COVID-19 pandemic, we adults are at various distances outside the eye but nevertheless in the throes of the storm. With varying degrees of difficulty, we all are enduring this disorienting threat – one that affects our health, economic security, and our sense of normalcy. In a word, our world has been upended. Even the news cycle, which is somehow faster than it’s ever been, resembles gusts of wind, bellowing the same basic stories as it whips up feelings of impotence, frustration, and anxiety of an unknown future. Blasting our faces, burning our eyes and pushing us backwards. Most children, however, do not share our experience. They see the world around them – they see us –from a very different vantage point. They sit in the eye of the storm. For them, life is unstable in a different way. It is not the frenetic energy of trying to keep everything together. It is the restless energy of not being able to be a kid. Their sense of loss in this moment relates to the missed opportunities that childhood used to bring – only a few months ago. No longer can they play outside with their friends, visit their extended family, look forward to prom, plan for summer vacation. For the moment, all is quiet. All they can do is sit, holding their breath, as they watch from a distance the chaos that surrounds them yet does not envelop them. The disruption of stopping is greater than the disruption
of moving at a different speed or pivoting in another direction. Think of it this way – when we run on a treadmill or play a game of pickup basketball, we can change our pace or move to an open spot on the court without really thinking too much. In continuous movement, we react in ways that keep us engaged. If, however, we get off that treadmill or take a break in the game, it is much harder to return to the pace we kept before. Starting to move again takes intention and effort.
We also can see how our values are being tested through our difficulty to act on them at these times.
This hiatus is hard for children. We should not minimize their experience or close our eyes to their pain. We should see how the pandemic is affecting them, knowing that the longer the interruption the harder it will be for them to pick up their pace again. However, maybe that is not such a bad thing. Maybe their necessary stepping off the college preparatory treadmill provides the needed time to consider whether they – or we – even want them to continue or if we all should switch our attention to something else.
When the dust settles, we hope that all of us will have gained an appreciation for the things that can’t ever be bought – like family, friends and human connection. Money will no longer be seen as a means to buy us love. What we once perceived as the little things, like having dinner with grandparents, spending time in the company of friends—even riding on a school bus on a sunny day with the windows open— will become a moment of joy and a feeling that all is well with the world.
Before the pandemic, social distancing was a byproduct of spending too much time online. Now that it is intentional, we are beginning to see and understand the consequences of losing personal and physical connection to others. Before the pandemic, economic growth was taken for granted and social identity was a means for distinction. Now, we recognize the pitfalls of overly optimistic economic assumptions. And we see how emphasizing distinction rather than difference can tear a country apart at a time when unity (not homogeneity) is needed. Only a few months ago, food in America was a given, with obesity being a public health concern. Today, our ability to buy food is disrupted, either due to supply chains, market forces, or our fear of going to the supermarket.
We hope that the generation of kids who were robbed of their over-programmed schedules but given endless hours of independent imaginative play will come to realize how valuable was the trade-off. We hope that the time alone serves to stop the rise of social loneliness and becomes a generational reboot for what it means to be comfortable in one’s own skin. This time in the eye should be a time for children to learn how to cultivate themselves and their own interests, so that they don’t have to rely on a curated world which targets them as consumers.
As we desperately cling to a semblance of our former lives and our children sit watching us with nothing better to do, we all recognize that the pandemic razed the idols of our carefully curated lifestyle. Our former “see it, want it, buy it” mentality has been challenged by the realization that parents and children alike barely miss shopping malls, but desperately miss face-to-face human contact. We have forgotten to care about what our neighbors are wearing or driving, but we have remembered to care about how they are doing. It is not that we don’t miss our lives and disposable income, or that our values have changed. Rather, it is that what we used to think was essential is now recognized as being the luxury it always was.
Children learn how to act, speak, and live from their surroundings. They get their priorities and interests from copying the people they respect and love. They will learn how to live through their own hurricaneforce affront by watching how well we push through ours, even if they don’t fully understand today what we are going through.
Hope alone does not cause any of these dreams to become reality. And many of us are just way too busy to move the railroad switch, enabling our kids’ life train to take another track. Many of us might not even have the energy to imagine another track is possible. But it is possible – we just have to have the will to see it. Generations are defined by more than birth years; they are defined by moments. The COVID-19 pandemic is certainly a moment. Our hope is that the moment the COVID-19 pandemic serves is one that allows our children to question society’s goals and values so that we move forward and not backwards to how we once lived. As appeared in Simply Family Magazine on May 15, 2020.
AFTERWORD Edward C. Halperin, M.D., M.A. Chancellor and Chief Executive Officer
days as 17,000 newspaper workers walked out. Over the next few years, most of the papers went out-ofbusiness. Of particular importance was the closure of the upper crust New York Herald Tribune—a direct competitor to The New York Times with a Republican tilt to its editorial pages. When the Herald Tribune disappeared in 1970 it had repercussions in my home. My mother didn’t like the font of The New York Times so we subscribed to the Herald-Tribune, New York Post,
Newark Evening-News, Somerset Messenger-Gazette, and Jewish Standard. With the disappearance of the Herald-Tribune, the leadership of the Times felt they had an obligation to break a longstanding newspaper tradition of the only writing which appeared on the editorial page and the facing page was produced by employees of the paper, including paid opinion columnists.
The New York Times deserves credit for the invention of the “op-ed” in 1970. As a child growing up in the New York metropolitan area in the 1950s and 60s, years before that first op-ed was published, I was accustomed to a world full of morning and afternoon daily newspapers. They were The New York Times, New
York Herald Tribune, New York Journal-American, New York World-Telegram and Sun, New York Mirror, New York Daily News, and New York Post. Two Long Island papers, the Star Journal and Daily Press, were counted among those serving the metropolitan area.
Across the Hudson River there was the dignified Newark Evening News, “the paper which made governors quake and brought the state legislature to its knees” and the far less dignified Newark Star-Ledger. The Village Voice began appearing as a weekly in 1955 and covered what we called, at that time, “the counter culture” or “beatnik” worlds. There was a vigorous group of black newspapers led by the New York Amsterdam-News. Then there were the non-English language daily newspapers in Spanish (El Diario La Prensa), Yiddish
(Forverts, Der Tog, Morgen Zshumal, Morgen Freiheit) German (New Yorker Staats-Zeitung), and Italian (Il Progresso Italo-Americano). There was also, of course, The Wall Street Journal but I didn’t know anyone who read it unless they were required to do so by their professor for their freshman college economics course. Among my enduring childhood memories, I recall my parents walking around the house looking for today’s copy of one of the papers they had not yet read. “Ruth, did you see today’s Post?” Then came the crushing strike of 1962, shuttering all of New York’s English language daily papers for 114
Instead the Times created the idea of an “opposite to the editorial page” or “op-ed” wherein previously unheard voices could express themselves. Thus, the oped was born and 50 years later with the transformation of much of journalism from print to electronic formats, the op-ed as a means of expression lives on. Why do people bother to write op-eds? A few, I suppose, are motivated by the desire to see their names in print. Most, however, feel that they have something useful to say and hope to cajole, persuade, or influence others to either agree with them or, at least, continue the dialogue about issues of public concern. Why do people read them? Because they want to get different points of view and be entertained by good writing—as long as that good writing doesn’t exceed approximately 750 words. You have to wonder how historians will describe the ways we as individuals, our institutions, and our society responded to the challenges posed by the COVID-19 pandemic. Perhaps some historian will come upon this collection of op-eds and opinion columns and use them to understand how we came to grasp what was happening to us and how to respond to it. We can, at the very least, take pride in the fact that the views and voices of the faculty of the New York Medical College were expressed and, we hope, made a positive contribution to dealing with the pandemic. I hope you have enjoyed reading this collection of essays, columns, and op-eds and, just maybe, think about things a little differently than you did before you read them.
CONTRIBUTORS Salomon Amar, D.D.S., Ph.D., vice president for research, professor of pharmacology and microbiology and immunology at NYMC and provost for biomedical research at Touro College and University System
Robert W. Amler, M.D., M.B.A., dean of the School of Health Sciences and Practice, vice president for government affairs, and professor of public health, pediatrics and environmental health science
Amy Ansehl, M.S.N., D.N.P., FNP-BC, associate dean for student experience, associate professor of public health, executive director of the Partnership for a Healthy Population and assistant professor of family and community medicine
Ira J. Bedzow, Ph.D., assistant professor of medicine and director of the Biomedical Ethics and Humanities Program
Adam E. Block, Ph.D., assistant professor of public health in the Division of Health Policy and Management
George W. Contreras, M.E.P., M.P.H., M.S., CEM, FAcEM, assistant director of the Center for Disaster Medicine, assistant professor in the Institute of Public Health of the School of Health Sciences and Practice
Stacy Gallin, D.M.H., visiting assistant professor of medicine in the Biomedical Ethics and Humanities Program
Vikas Grover, Ph.D., CCC-SLP, assistant professor of speech-language pathology
Edward C. Halperin, M.D., M.A., chancellor and chief executive officer
CONTRIBUTORS Adam S. Herbst, Esq., adjunct assistant professor of medicine in the Biomedical Ethics and Humanities Program
Marina K. Holz, Ph.D., dean of the Graduate School of Basic Medical Sciences and professor of cell biology and anatomy
Alan Kadish, M.D., president
Lila Kagedan, M.Ed., adjunct assistant professor of medicine
John Loike, Ph.D., professor of biology, Touro College and University System
Padmini Murthy, M.D., M.P.H., M.S., M.Phil., CHES, professor of public health and director of the Advanced Certificate in Global Health and clinical assistant professor of family and community medicine
Jennifer Riekert, M.B.A., vice president of communications and strategic initiatives
Julio A. Rodriguez-Rentas, M.A., director of communications
Angela Rossetti, M.B.E., M.B.A., adjunct assistant professor of medicine
This publication is dedicated to the clinicians, health care professionals, researchers, scientists, and the many workers, who spend countless hours, day and night, on the frontlines across the country and around the globe to help keep their communities safe from COVID-19. Sincere thanks to the committed members of New York Medical Collegeâ&#x20AC;&#x2122;s public relations team â&#x20AC;&#x201C; the exceptionally skilled and creative individuals who served as the invaluable force behind the entire process that results in Pandemic Perspectives. Thank you to the authors who took the time to lend their voices and expertise in order to educate and inform the public amidst this health crisis.
The opinions expressed herein are those of the authors and not of New York Medical College. New York Medical College assumes no liability of any kind for its accuracy or completeness, or responsibility of any omission as it is not deliberate.
Where Knowledge and Values Meet
About Us Founded in 1860, New York Medical College (NYMC) is one of the nationâ&#x20AC;&#x2122;s largest private health sciences colleges. A member of the Touro College and University System, NYMC is located in Westchester County, New York, and offers degrees from the School of Medicine, the Graduate School of Basic Medical Sciences and the School of Health Sciences and Practice, as well as a school of dental medicine and a school of nursing. NYMC provides a wide variety of clinical training opportunities for students, residents and practitioners. The College has a strong history of involvement in the social and environmental determinants of health and disease and special concern for the underserved.
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