Let’s get clear on what the problems really are, then divide and conquer.
Recently I recalled one of the most crucial things I learned in medical school: the power of the “problem list.” Each patient came to us with a diagnosis, which was the reason for hospital admission. But as our attending made clear: the easiest and most efficient way to address the condition was to separate it into its component parts. It no longer becomes “let’s manage this patient with dementia,” it becomes “let’s sort out what the smaller problems are that make up the bigger challenge of treating this dementia.” We then understand how each smaller problem feeds into the larger one, which ultimately leads to appropriately managing the patient’s disease.
Tackling COVID-19 in America is an overwhelming and gargantuan task with no clear pathway, with everything so far pointing to failure. Much like how psychologists recommend “chunking” for learning, parsing out a big problem into a smaller set of problems helps us organize our thoughts, delegate tasks appropriately, all while making sure we’re not overlooking anything. It also helps us create contingencies and monitor progress.
If America was a patient, this would be her problem list and items to delegate:
1. Unclear case definition and endpoints
Infectious disease experts must help us more clearly define what a COVID-19 case looks like: the virus attacks the respiratory system, but other systems, like the gastrointestinal system, may also be affected. It also appears that the inflammatory response (how the body responds to the virus) as opposed to the virus itself, may be the primary cause of mortality, and this dictates treatment. Given that the tests available are imperfect, a negative test, in the presence of symptoms, should be treated as a presumptive case. Once a case definition is established as universal, it should further be stratified as mild, moderate and severe, with objective criteria defining each. Our metrics of response success must also be determined: COVID-19 is an unprecedented pandemic that is positioned to barrel through the U.S. and kill anywhere from 100,000 to 1 million people. Is a successful response one that cuts the most conservative projections by half? And are we more concerned about minimizing infections (of which most will be mild) or is the bigger priority to minimize the number of deaths?
2. Confusing public health messaging
Clear public health messaging is a challenge especially during times of uncertainty. Currently the messaging on whether transmission can occur through the air remains inconsistent between the World Health Organization, Centers for Disease Control, the White House, and state governments. This contributes to the spread of the “uncertainty virus” and mistrust, not unlike in a hospital when multiple teams are involved where medical errors are often secondary to communication issues, and was especially so with the case of masks. Groups like Choosing Wisely have disseminated some evidence-informed, best practices but clear public health messaging needs to be centralized. The White House should delegate one expert, ideally Dr. Anthony Fauci, to disseminate up-to-date public health information clearly and succinctly while also communicating uncertainties. Editors of major media in print and online challenged with this crisis will also play a key role in presenting consistent and reliable public health messaging. For months experts as well as the media underestimated the threat of COVID-19, and while contrarian views can help dissuade groupthink and tunnel vision, they risk undermining public health best practices and expert consensus. It is not a black swan. Rather, it was a dark horse: an underdog, one we were too blinded to see coming. We’ve seen dark horses before.
3. Insufficient testing
We need to clarify what we mean by “ramp up testing.” Tests should be two-fold: of secretions for the presence of the virus (presence/absence, and quantitative viral load data if possible) through a swab of the oral cavity and serologic testing for protective antibodies (which dictates prior infection, and likely protection) ideally with a fingerprick test. At this stage home-based testing might make the most sense, and it’s crucial to test a number of candidates against the gold-standard hospital-based test. An ideal test kit might have: a link to an online symptom checker, the swab and fingerprick test, and a self-addressed return envelope to mail back the test to a state lab. Once a kit (which would be priced at $0 to the public) is created, a partnership with Amazon (similar to what was struck in Canada) might make the most sense, given their warehousing and shipping capabilities, but we must ensure their delivery workers are provided with protective gear. Additional tests should be disseminated to homeless shelters. The tests won’t reach everyone, but capturing at least 75% of the population should be enough. As a metric we must set a benchmark for the number of Americans we want tested by April 30th.
4. No clear clinical pathway after a positive test
In China, positives were quarantined away from home. Had we organized early enough we could have used empty hotels for this purpose. Instead we should model symptom monitoring recommendations after asthma action plans, which are based on the traffic-light method. An expert committee — possibly from the American Academy of Emergency Medicine — could create a similar system (for instance, including symptoms like fever for a specific number of days, shortness of breath, and so on) so that those with a positive test know when to go to the hospital. We have enough data now, based on thousands of cases, to create this system.
5. Challenges with logistics, manufacturing, and procurement
While exciting, searching for a vaccine is not the biggest issue right now. Instead, it’s logistics, manufacturing and procurement, and this requires organized and thoughtful public-private partnerships. To be clear, the Defence Protection Act must be formally implemented with clear directions for the manufacturing of ventilators (ideally portable bedside ventilators as these would work better in make-shift hospitals without ready access to outlets), n95 masks, face shields, and gowns for healthcare workers. But currently this is highly decentralized which contributes to chaos: so formally involving the Defence Logistics Agency will also be key. Delegating these tasks to a few major companies who have the ability to manufacturer and ship their products quickly is crucial. We must also set clear pricing: a Forbes investigation recently found the inability to effectively negotiate contributed to the undersupply. Companies like Apple have people skilled at negotiation and procurement, and could offer their most skilled specialists to assist in ensuring we get supplies we need for the next 2–3 months, which appears now to be a focus. Outside the box solutions such as mask sterilizing systems should also be scaled up as well.
6. Lack of a universal policy, treatment, and end-of-life algorithms
We don’t have expert consensus on institutional infection control policy, nor treatment, discharge, or end-of-life best practices. As such, we should consider rapidly adopting a universal infection control policy modelled on Partners Healthcare and have an expert team, perhaps from the Society of Critical Care Medicine use the currently available evidence to create an algorithm for care, stratified by mild, moderate and severe. While imperfect, it will provided a road map that can be refined as we learn more, and would replace the informal crowdsourcing of best practices on social media. An ideal algorithm should dictate the parameters for oxygen, what starter therapies (medications and fluids) might help, criteria for mechanical ventilation (and settings), when to provide experimental treatments (e.g. chloroquine and remdesivir) for compassionate or trial us, and when to discuss comfort care. While abiding by infection control practices, everything possible must be done to allow family members to be present with their dying loved ones — walkie talkies goodbyes aren’t enough. Eack patient that enters the hospital with COVID should have an advanced directive regardless of how severe they are on admission. Given that some deaths have occurred after discharge, every COVID patient released from hospital must have a clear set of criteria on what to do at home, and when to return.
7. Unprotected healthcare workers & whistleblowers
Though doctors may be enlisted, many are struggling with their duty to serve, preparing their wills, and protesting seemingly to deaf ears for personal protective equipment (PPE). Thousands of healthcare workers around the world have died, including at least two resident doctors. The death of New York City-based Dr Frank Gabrin, himself a proponent for physician wellness, need not be in vain. We must have PPE for each healthcare provider, replaced at least once a shift, while also allowing for sufficient recovery time between shifts (in New York, having doctors and nurses serve from around the country helps with this). Punishing whistleblowers was seen first in China and but is creeping up in the U.S among healthcare workers and the military — this reprisal demonstrates a lack of psychological safety which will only worsen outcomes. Everything must be done to protect those that speak up.
8. Scattered research and no centralized database
While it’s promising to see so much research on therapeutics happening all over the world — snippets shared over social media are mostly of case reports and small trials. We must create a central research database of existing studies — Stanford has a good starting model. Many research questions still remain. We could also leverage electronic medical record systems to help central database of diagnoses, clinical course, and outcomes.
9. Exacerbations of existing inequities
As with any patient, the social history cannot be forgotten. We need to get clear on what Americans with chronic health conditions should do if they can’t get care as they are at risk for dying due to lack of care during this crisis. We must also make every effort to protect and serve the most vulnerable who are at higher risk of poor outcomes — African Americans, those in the South, as well as the homeless and the undocumented (who may often be ‘essential’). Indeed as Alexandra Ocasio-Cortez tweeted last week, “inequality is a comorbidity.” It will be a stain on this nation if this crisis further perpetuates existing inequities. Ensuring healthcare during this time is accessible and universal, as recently underscored by the WHO is key, and could be inspired by other promising social experiments.
10. No clear plan for the “echo pandemic” of mental illness and social unrest
We are beginning to see an echo pandemic of mental illness and we may also see a rise in social unrest the longer we stay in lockdown. We must plan for both of these. To start, mental health experts should, where possible, offer services virtually. City planners must prepare for a possible surge in domestic violence, looting, and rioting. Notably, given the policy around face coverings, many perpetrators of public crimes may be difficult to identify.
This is America’s problem list; it is by no means comprehensive but it might be a starting point to help a strong leader delegate tasks. We can benefit from post-mortems from SARS and study the pandemic response now. As economist Daniel Kahneman popularized, we should also consider creating a premortem — anticipating how our response will fail helps us prioritize an action plan. The first step in any situation and assessment is realizing that one big problem is really a set of smaller problems and progress involves working diligently to address each component part. The intent is not to oversimplify but to make the task of battling COVID-19 more manageable while minimizing decision fatigue and maximizing public trust.
The time is now to divide and conquer. COVID-19 is not a drill. It’s a bitter pill.