The Wisdom of the Crowd

 

I am not going to write a weather-related piece today, as everyone is likely receiving plenty of information through the usual sources.  As I write this, it is mid-day Wednesday and it the path of Hurricane Laura is becoming more certain.  It appears it will not hit Houston directly, which if forecasts hold would help to mitigate the impact.  However, many are still directly in the path of a very dangerous storm, and our thoughts and/or prayers are with them.  Our support will be needed in the aftermath.

 
Obviously, there is concern about what impact this event could have on our COVID-19 outbreak.  If large numbers of people are displaced, and forced into congregate shelters, this will create a risk of spread of COVID-19.  Public officials have taken steps to limit the size of shelters and incorporate distancing principles into their design and operation, but any significant population displacement will place additional pressure on disease control efforts.
 
So with that brief nod to the issue that is on everyone’s minds today, I will return to an update on COVID-19 issues.  A couple of weeks ago, I posed the question to all of you: “If you were advising one of our presidential candidates, or local leadership, or a company executive on preparation for the next global pandemic, what is your priority?”  You emailed your responses to me, or posted them on Twitter using the hashtag #TheNextPandemicBCM where they are still available for review.  Following a brief review of our COVID-19 numbers, I want to report what you said.
 
The COVID-19 numbers continue to trend well, for the most part.  From prior posts, you know we are focused on three primary metrics: R(t), diagnostic test positivity rates among TMC facilities, and the number of new daily COVID-19 cases in Harris and surrounding counties.  
 
Recall the R(t) calculation is an estimate of viral infectivity, influenced by the properties of the virus and community dynamics.  Simply put, if I am infected with COVID-19, the R(t) is a statistical estimate of how many other people I am likely to infect.  If R(t) is less than 1.0, Houston is winning; greater than 1.0, SARS-CoV-2 is winning.
 
Even with a highly infectious virus (like measles), if we are truly and completely isolated from everyone else – a condition which only exists as a hypothetical – the R(t) would be effectively zero.  Conversely, if we all tend to congregate in crowded spaces with poor air exchange for prolonged periods of time, even a virus which is not inherently very infectious could have a very high R(t).  This is why attention to masking and distancing is so important.  The good news this week is the R(t) has been consistently less than 1.0 for 16 consecutive days.  As of now, we are winning.
 
Our second metric is the rate of positive tests among all tests ordered by Baylor and other TMC affiliate institutions.  This is a rough gauge of viral prevalence, which we would like to see sustainably below 5%.  The TMC positive test percentage is now 6.7%, and has been slowly trending downward.  This is not where it needs to be, but is headed in the right direction.  If you follow the city, county and state numbers, you will note that their percentage positive tends to be a few points higher.  This probably reflects some selection bias on the part of the Baylor and TMC facilities cohort.  Although we test symptomatic people in our ambulatory clinics, much of our testing is asymptomatic employees in surveillance programs, and asymptomatic patients admitted to hospitals, who would be expected to have a low positivity rate.  
 
However, we are very confident in the integrity of the data point we generate, which is why we have chosen this as our metric.
 
Finally, our most problematic metric: new daily COVID-19 cases in the community.  This number is (very) slowly drifting down, and on a 7-day rolling average basis is between 1,400 and 1,500.  This is good news is that in mid-July we were at about 2,400 cases.  However, we are still seeing 5-6 times the number of daily cases compared to May, and for public health officials to have a realistic chance of performing effective contact tracing it needs to be closer to 200.  This metric is the most methodologically flawed, for reasons I have previously reviewed, but should be increasingly reliable as state data issues are resolved.
 
In summary, the trends are encouraging, and hopefully future community stressors like school reopenings, the Labor Day holiday, flu season, etc. will not set us back.
 
Please continue to preach the masking and distancing message to your circles of influence.  
 
I hope we as a nation will get to a point soon – we are not even close yet – where we can stop managing the crisis in front of us, and begin to focus on how to be better prepared for the next pandemic.  That was the point of the five word #TheNextPandemicBCM exercise.  Roughly 100 people from the broad Baylor community responded.  Some people responded with tactical concerns, such as the need to stockpile PPE. A few made – mostly respectful – statements favoring one side of the political spectrum or the other.  Most responses addressed broad, fundamental key principles.  Taken individually, none of the principles is particularly surprising; however, there were four major themes when taken together constitute a thoughtful outline for how we can be better prepared next time – the BCM crowd-sourced pandemic preparedness plan:

• Elevate the role of rigorous science in public policy.  Example of five words: Build public confidence in science; Clear communication improves scientific understanding; Trust scientists and not Facebook.  Fully one quarter of respondents reflected this theme in some way.  
• Build reliable data and reporting systems.  Five words:  Worldwide electronic medical interconnectivity; Good data drives good decisions; Reliable information must unite us.  
• Invest in public health infrastructure and education.  Your words: Comprehensive integrated public health network; public health in high school; Public health investment dollar well spent (technically, this last one is six words, but it was too good not to include)
• Effective leadership is critical. Effective leadership: national, regional, local; Good leadership drives action; Clear messaging from leadership unites.

Our limited “Twitter poll” is obviously not a methodologically sound, comprehensive analysis of our current state nor an attempt at meaningful future planning.  However, the Baylor community does represent an interesting collection of researchers, educators, clinicians and learners.  Our exercise does represent a limited snapshot of the mood of this community at a time we were still actively engaged in our struggle with the virus.  Based on this snapshot, we should be advocating for public health curricula across the entire educational landscape: elementary to graduate school.  Our more informed populace will need reliable data presented in an accessible manner.  Our scientific community will continue its long-established commitment to academic integrity.  Leaders need to be able to promote an environment of trust and confidence.  These concepts may seem so obvious as to be trite.  However, if we do not actively work to address these – and no doubt other – issues now, our motivation and sense of urgency will flag as COVID-19 fades into memory.  As a learning health system, we have an obligation to hold our societal feet to the fire.
 
Stay well and stay safe.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

D-Day

This week’s message may be slightly longer than usual, but I hope you will read it to the end.  As the viral dynamics continue to improve in and around Houston, I want to pause to recognize a group that has borne a disproportionate brunt of pandemic-induced pain – our front-line health care providers (HCPs). Theirs is a compelling story.

 
Before I proceed, I will very briefly mention this week’s data.  Our “R(t)” value is less than one (so we are winning).  Hospital COVID-19 related census levels continue to drop steadily.  The rate of new community cases is declining, albeit more slowly than anyone would like.  The percentage of people with positive tests is declining.  This is all favorable news.  If you are not familiar with some of these terms or concepts, please refer to last week’s message for more details.
 
Things are looking up, but I must revisit a persistent theme in these messages:  We must remain vigilant; we cannot become complacent.  Mask, distance, and avoid crowds.  Settle in for the long haul because we will need to live cautiously for months if we are going to be able to open up schools and maintain something that approximates our pre-COVID life.  Again, refer to last week’s message for more details.
 
Now, on to front-line HCPs.
 
Every one of us has suffered, to varying degrees, during this pandemic.  I have two new granddaughters, one born in September, and the other in June.  I consider them both pandemic babies, born in a strange time.  My younger granddaughter is named after her great-great aunt, who was an Army nurse, and part of the mobile medical response team that landed with the D-Day invasion in World War II.  She has since passed away, but in all the years I knew her, I never heard her talk of her experience.  I suspect it was horrific.  Everyone in the United States suffered during WWII.  There was fear of a mainland invasion, rationing of food, coffee and fuel, and shortages of rubber directed to the war effort.  However, given that during D-Day almost 3,000 Americans died, and four times that number were wounded, most would agree that the suffering of the many back home did not compare with the experience of those who stormed the beaches.
 
Have I suffered during the pandemic?  The honest answer is “yes, but…”  
 
Yes.  I have worked a little harder than normal.  In welcoming our pandemic babies to the family, we have cancelled baby showers and missed a large family gathering for a baptism.  We have not been able to jump on a plane for a quick visit.  Everything is a little more complicated, and a little less convenient.  To be sure, we feel fortunate that we have not suffered loss of livelihood, or health, or life – as many have.  
 
So we have suffered, but not to the extent of our front-line HCPs.  In this SARS-COV-2 war, they are the soldiers, and our ICUs are the beaches of Normandy.
 
In preparation for this piece, I spoke to about a dozen inpatient front-line HCPs in several Baylor affiliates: Baylor St Luke’s Medical Center, Ben Taub Hospital, and Texas Children’s hospital.  I spoke to intensivists and hospitalists; nurses and residents.  I wish I could have spoken to them all, as they all had an important story to tell.  What follows are a few of my questions to them.  The responses are their words, not mine.
 
We have been dealing with this crisis now for six months.  Tell me about your hardest day during that time, and what made it hard?

• My hardest day was when I worked my first shift in a newly-designated “all-COVID” unit.  All the patients were incredibly sick.  There were multiple codes.  I couldn’t leave one patient’s bedside long enough to attend to the next one.  I went home and cried.  I had to let it out.  It was one of the worse days of my life.
• Watching a young patient deteriorate before my eyes; seeing families devastated by the disease affecting multiple people.
• We are a people called to care.  In the early days, there was nothing we could do that seemed to help.  It is hard when you can’t see a path forward.
• I always try and take care of my people.  I couldn’t help them.
• I was worried about my family – that they would contract the disease.
• It was physically grueling work.  At any given time, 70% of our ICU patients were on a proning protocol.
• It is very hard to take care of sick kids when both parents can’t visit, they can’t see my face though my mask, and I can’t sit on the edge of the bed.

What single word best describes your feeling on that day? 

• Draining (multiple responses)
• Helplessness
• Overwhelmed
• Numb
• Anger (at the lack of resources in the early days, at the community at large for not taking this seriously)
• Despair

What did your team of health care providers do well?

• We had a shared spirit, and collaborated broadly.  It was one of the most rewarding experiences of my life.
• I was proud of our new faculty.  They were fearless.
• Everyone was committed.  Everyone sacrificed family responsibilities, vacation time.  We all worked long hours.
• We really rose to support each other. I was incredibly impressed and proud. Teamwork.
• We adapted rapidly, and learned quickly.  We became masters of data-driven micro-innovation.  We are better for this experience.
• Even though everyone was already incredibly busy, we held frequent Zoom meetings with regional hospitals to review cases and treatment protocols.  We felt an obligation to help build capacity and improve quality across the region, just not in our hospital.

Imagine a time when COVID-19 is truly behind us.  What is the single biggest lesson we should have learned from this experience?

• Our health care community is incredibly valuable.
• I cannot function without a great team around me.  I have an overwhelming sense of humility, and gratitude for my colleagues.
• We need to be ready next time. 
• Stockpile PPE.
• Enhance our public health systems – earlier control, more effective contact tracing.
• We have a leadership responsibility for the region.
• Life is precious, but uncertain and fragile.
• Putting others first is the best way to take care of yourself.

I hope we learn these lessons.  I hope our front-line health care providers differ from the survivors of the Normandy invasion in one important way – I hope we continue to talk about these experiences.  Experiences that have been incredibly hard, but at the same time affirming and formative.  As one person commented, “talking about this has been very therapeutic.”
 
In closing, I want to express my admiration and gratitude to everyone in our professional community who has been on the front lines sacrificing to provide extraordinary care in extraordinary times to our families, friends and neighbors.  May we never forget.
 
What would you like to communicate to a front-line health care provider?  Using exactly five words, post to Twitter using the hashtag #COVIDThanksBCM, or send your five words to svpclinical@bcm.edu, and I will post some of your responses.  Also, as many have asked, feel free to share this message broadly. You can copy and paste this link to email messages or social media: https://bit.ly/3277mrt.

So what are your five words of thanks?  I will start, with apologies to Winston Churchill:
 
This was their finest hour.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).