As the COVID-19 pandemic continues to unfold and the number of identified cases rises dramatically in the U.S., we again talked with our editorial director, John Swartzberg, MD, for his perspective on the week’s developments. Here is an edited version of our conversation from the evening of March 23, 2020.
How does what we’re seeing reflect long-term changes in health care systems?
I’ve been working in hospitals since 1970, when I graduated from medical school. At that time, hospitals were less focused on the bottom line. The business model now is driven by the concept of efficiency, and that translates to the idea that empty beds are not efficient. So you want to make sure hospitals are filled up, that we have only as many beds as we need at any given time as predicted by past experience. That means that overall we have far fewer hospital beds than we used to.
And it’s also not efficient for hospitals to have extra ventilators or masks and other kinds of personal protective equipment (PPE). In general, it’s much more efficient to have a supply chain that sends you items just when you need them. And that might be sufficient for normal times. But this crisis demonstrates how short-sighted that kind of thinking can be. It’s a big reason we’re in the position we are in now.
Is that part of a larger trend of underfunding public health in general?
Yes. If we can’t afford to have a health care system that plans for something catastrophic, then why can we can afford to spend so much of our GDP on a military that plans for wars we won’t end up having? Why don’t we treat the health care system the same way, and have hospitals that have sufficient surge capacity? We have pandemics on a fairly regular basis, but they’re just long enough apart that human beings tend to forget about them.
This is not an argument against the military. It’s really an argument that we ought to find ways to pay as well for a health care system that make us feel secure. In fact, we’ve been underfunding the Centers for Disease Control and other critical public health needs for decades, including for pandemic planning. That’s like underfunding the military, and then war breaks out and you have to fight it with suboptimal resources. I don’t think people appreciate how underfunded public health is.
Shouldn’t we have learned the importance of being prepared after the SARS epidemic in 2003?
Yes, but we didn’t because SARS had minimal impact on us in the U.S. Look at South Korea, Singapore, Taiwan, and Japan—they were beaten up by SARS. Those countries remained more vigilant and prepared to respond to a pandemic, and they acted quickly to find and isolate cases of coronavirus. In contrast, the U.S. was barely hit by SARS, so we didn’t do much in terms of ramping up preparedness.
How are hospitals and the health care workforce faring so far?
There are hospitals in the Bay Area and some other areas that are already stretched thin. They’ve used up about all their isolation units, they have almost no empty ICU beds, they have one ventilator left. They’re now re-using protective masks that are supposed to be used once and discarded, looking at ways to sterilize them between use. At the University of Nebraska, they announced that they’re taking their used masks and putting them under UV light. No one’s ever carefully tested whether this works and if it leads to suboptimal performance of the masks.
We are seeing health care workers put on furlough because of exposures to coronavirus. We’ve mostly been able to compensate so far. But when we get the surge that we expect, it could be a huge problem. So it’s a perfect storm. We have health care workers without sufficient PPE, and we don’t have enough health care workers, and those we do have will be more likely without PPE to get sick or have to go into self-quarantine.
How long do you think we will have to continue “sheltering at home”?
It’s really too soon to say. When we start to see an effect from this strategy, then we can start to consider when we might be able to gradually remove the restrictions. I don’t think early April is realistic, although we might have enough information by then to get some idea of what lies ahead. Because of the lag in testing, the numbers we see now are really giving us a picture of where the epidemic was a week or so ago—they are much lower than the actual number of people already infected. In California, we’re just at the point of the curve where within the next two weeks the numbers are going to start to shoot up dramatically. New York is probably a week ahead of California.
Testing is now starting to increase slowly and will continue to ramp up. In the next two to three weeks, we’re going to have identified a lot more people. That means that even if the sheltering at home is helping, which I think it really will, the beneficial effects are going to be offset and masked somewhat by the increased caseload that we identify through expanded testing. So it could take some time to assess the impacts of sheltering at home.
What is the current state of testing availability?
In spite of what we’re told by the executive branch of the U.S. government, the tests are not readily available. The administration has been saying that anybody who wants to be tested can get tested, and that has never been true. The state of testing is improving, but we still have to severely restrict who is being tested to save the tests for those who need them the most—people who come in very sick and need to be tested so we can find out what they have, health care providers who have been exposed, and some others.
How would you assess the Trump administration’s performance?
At the time of a pandemic, when people are terribly frightened, we need leadership that promotes trust in government. President Trump has done the opposite of that, with his prevarication and inconsistent messaging, by contradicting himself and his own medical experts. And government agencies hear what the president says. If you know the boss wants to keep the numbers identified as having coronavirus low, and you want to please the boss, maybe you won’t pay as much attention to testing people as you should. When you know the person who is your boss is giving mixed messages and even lying, how do you run the CDC? How do you run the FDA? How do you run these institutions?
Also see these earlier articles:
- Protecting Your Eyes from COVID-19
- COVID-19: By Staying Apart, We’re Working Together
- COVID-19: An Update
This opinion does not necessarily reflect the views of the UC Berkeley School of Public Health or of the full Editorial Board at BerkeleyWellness.com.