While children seem to be less susceptible to SARS-CoV-2 (this is my guess at this time) or alternatively, if they are just as susceptible but tend to disproportionately get asymptomatic disease from the novel coronavirus that causes COVID, there is a rare complication that may be caused by COVID that we are only seeing in children – Pediatric Inflammatory Multisystem Syndrome (PMIS).

PIMS resembles a disease that we are already familiar with – Kawasaki disease, but yet there are important differences. Kawasaki disease is a vasculitis, i.e., an inflammation of blood vessels, in this disease typically inflammation of mid-sized arteries, which can lead to one of the worst complications of Kawaski disease – aneurysms of the coronary arteries and impairment of heart function.

In Kawasaki disease, children often have recent respiratory or gastrointestinal symptoms, and then become more ill and present with fever, redness of the eyes (conjunctivitis), red and cracked lips, a red and swollen tongue and redness inside the mouth, rash, swollen lymph nodes in the neck, painful joints, redness of the palms of the hands and the soles of the feet, peeling of the skin over the hands and feet, abdominal pain, vomiting and/or diarrhea. Most often these children are under the age of 5.

Although there can be serious complications, most children recover fully from Kawasaki disease.

We don’t know what causes Kawasaki disease, but it seems to follow an infection in children (which suggests that it may be a consequence of an overactive immune response) who possibly are genetically predisposed to developing Kawasaki disease. We treat Kawasaki disease with gamma globulin and aspirin, but many children will get better within two weeks, even without treatment.

During the SARS-CoV-2 pandemic, and as far as I know, just since April, we have seen children in Europe and the U.S. who have presented with an illness similar to Kawasaki disease, but in older children and often in a more severe form, often exhibiting signs of both Kawasaki disease and toxic shock syndrome (circulatory dysfunction), which can manifest as cardiac dysfunction and kidney injury.

While the greatest number of cases have been reported in the New York City Metro area, cases have been reported in California, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Massachusetts, Mississippi, New Jersey, Ohio, Oregon, Pennsylvania, Utah, Washington and Washington D.C., and perhaps in more states by the time of this writing.

While we are still learning about the many twists and turns associated with the SARS-CoV-2 virus, and have only recognized this newest manifestation of infection with this virus in the past month, here is what we can tell concerned parents today:

1. Children seem to be less susceptible to infection from this virus than adults. If, in fact, they are just as susceptible, then they seem far more likely to have asymptomatic infections.
2. Children typically only account for 1 – 2 percent of all the recognized cases of COVID in most populations, and at worst, perhaps up to 7 percent.
3. Even if children do get sick with COVID, they tend to do well, have mild illness and children rarely need the critical care serves and ventilators that are more commonly seen with middle-aged and older adults.
4. We still don’t know what role children play in transmitting the disease. That is to say, even if children do not get sick, but are infected, do they shed the virus and transmit it to other children and those in the household? So, while you don’t have to worry excessively about your children becoming seriously ill, you still need to be cautious about children, even those that appear well, coming into contact with those who are at high risk for this disease (the elderly and those with high medical risk).
5. This is an excellent time to teach your child, if old enough, about proper hygiene, hand washing, and how and why to cover their coughs and sneezes.
6. With all this said, even though most children will be just fine, if your child is sick, keep your child home. Contact your child’s doctor to let the office know about your child’s symptoms so that they can determine whether your child should be tested. Kids do manifest symptoms differently than adults and with COVID may be less likely to have fever or respiratory symptoms than is typical of adults.
7. If your child does test positive for SARS-CoV-2, you should assume there is high risk to everyone else in the household. Someone from the public health department will contact you and give you specific instructions, but two things – if it is practical, keep your child in one room of the house and have the child use one bathroom and everyone else use a different bathroom. Meticulously clean surfaces and regularly wash linens and pajamas. Minimize the number of other family members who come into that room and be extra careful about handwashing. If your child will tolerate it, have them wear a mask when anyone else needs to be in the room. And, secondly, you must consider that anyone at home living with the child is at high risk of being infected. Thus, it is best if everyone in the household remains isolated for 14 days to determine whether anyone else will develop symptoms.
8. The new condition I described above is still rare at this time, but we are seeing new cases all the time, so if your child does develop any of the symptoms I listed above, let your child’s doctor know right away.
9. It is always good to know where your closest children’s hospital is. If you need to go to the emergency room for evaluation and it does not appear to be imminently life-threatening, go to a children’s hospital if it is reasonably close by and call ahead to let them know you are coming. Of course, if the situation appears to be life-threatening or emergent, call 9-1-1 and go to the nearest hospital.

It is a common question that I have gotten, ever since I became a CEO more than 14 years ago – “What keeps you up at night?” I also get it now in regards to the coronavirus pandemic. I never tell anyone all the things that I am losing sleep over. It doesn’t do anything but cause others to lose sleep. The only fears that I share are ones that I think will actually benefit others to be aware of.

I was asked this question a couple of months ago in response to whether I was concerned about hospital bed capacity in Idaho. I replied that it wasn’t in my top 25 of things I worry about. A local business leader tried to Twitter-provoke me implying I should be worried about it. There are so many things to worry about, I have to prioritize my time spent worrying. He didn’t know what was in the top 25 on my worry list, or he would have understood why worrying about hospital capacity didn’t make it.

But time has passed. We have learned so much in the past two months. My list has evolved, but it hasn’t changed that much. I am not going to share my top 25 list, but I am going to share with you a few things that are on it, especially since some of these concerns have now made it into the press.

If you have followed my blog or discussed this issue with me, you know that I have been concerned for sometime about the predictive models that have been circulating in the media and online. They generally show a very nice, symmetrical bell curve graph that generally ends sometime this month or later this summer. Oh, that this were true. It would be wonderful. However, all of these models are inconceivable to me.

Why? Because the best guesses are that no more than 5 percent of the U.S. population has been infected with SARS-CoV-2. The limited antibody testing data available seems to support this. In fact, for Idahoans, that infection percentage is likely less than 2 percent.

As I have written previously, the lowest estimates are that it will take 60 – 70 percent of the population to be infected and/or immunized in order to slow down the transmission of the virus to the extent that the vulnerable and susceptible among us are relatively protected.

The only reasons that SARS-CoV-2 would stop causing infections this summer include (1) the attainment of herd immunity through natural infection (however, as I stated, best estimates are that only 5 percent of the country has been infected, so it is not reasonable to think we could get to the levels required for herd immunity anytime soon), (2) the attainment of herd immunity through immunization (however, there is no basis to believe that we could have an effective vaccine much before the end of the year, and even that would be an extremely aggressive timeline. Many experts are skeptical as to whether we will even have a vaccine next year), and (3) the virus mutates in such a way as to be far less contagious.

The SARS-CoV-2 virus is an RNA virus. RNA viruses are well known to mutate frequently. We know that there have already been at least 14 mutations of the SARS-CoV-2 virus just since late December/early January. Unfortunately, a mutation that probably occurred in February has already resulted in the virus likely being more contagious, not less and is likely the predominant, but not only, form circulating in Europe and the U.S.

My concern is that people seeing these depictions of models showing an end of disease activity this summer, the talk of reopening the country and getting back to work and school, and the early messaging about winding down the White House Coronavirus Task Force may lead many people to believe that we are nearing the end of this pandemic.

So, if the bell curve depictions are wrong or misleading, what does the future look like? With the caveat that no one knows for sure, I think a better depiction would look like a series of waves, where activity waxes and wanes. In other words, the number of infections will increase significantly, and then we will reinstate countermeasures that will bring the cases back down. But, with this said, I don’t expect that all the waves look the same. And, these waves will not look the same all across the country. The waves will be of greater amplitude in those cities of our country with mass transit, international airports, high population density and less effective social distancing.

So, if the virus is not going away this month or in the next couple of months as many of these diagrams suggest, what do these waves look like for the rest of 2020 and when do they come? There has been hope that the transmission of the virus would decrease over the summer with increasing temperatures, increased humidity and people being outdoors more. While we can still hope that is the case, it doesn’t appear very likely. First, we did not observe this in the southern hemisphere as those countries went through their summers. Additionally, it is likely that even if transmission is somewhat decreased, it may be offset by the large part of the population that remains susceptible to this virus (perhaps 95%). Further, my expectation is that we will see new waves of disease in the next three to four weeks (end of May/early June) that will result from reopening of communities in some parts of the country that are opening too much, too fast. Additionally, as travel resumes, we will have people bringing the virus with them to communities where they can significantly increase spread.

So, expect another wave by early June. I don’t think it will be as big as the first wave we have just been through since high risk individuals are largely continuing to stay isolated and even with the reopening, many people are choosing to continue to be reluctant to return to work, shopping and other activities until they see how things evolve.

On the other hand, I am worried about people who are falsely reassured by positive antibody tests. These tests are becoming widely available despite widely varying accuracy, a significant risk for false positive tests in low prevalence areas and a lack of evidence as to whether antibodies confer immunity. False positive tests could cause persons to exercise less prevention measures thinking that they are immune. We do know that most (but certainly not all) people who become infected do make antibodies to SARS-CoV-2. However, the immune response to SARS-CoV-2 is very complex and antibodies are only one small part of the body’s response. Antibodies are not produced until a week or more after infection. The initial immune response is non-specific (the innate immune response). If the virus survives this initial defense, it enters into cells to replicate and antibodies cannot reach the virus when it is inside cells. But, as virus is replicated in the host’s cells, the virus is released and antibodies can attack the virus. But not all antibodies do so or are effective in neutralizing the virus. We don’t know whether the antibodies to SARS-CoV-2 virus neutralize it, though there is good reason to expect that this might very well be the case. There are other viruses that also stimulate antibody production, but the antibodies do not provide immunity and do not stop the infection from continuing on, so we must take care to ensure that antibodies to SARS-CoV-2 are truly protective before we provide individuals with positive tests that impression or that reassurance.

We do expect that antibodies will confer some degree of immunity, but we do not know for how long. It could be for weeks, months or even a few years, but we don’t know. Further, the mutations identified that I referenced above have raised the question as to whether someone who is previously infected and develops immunity is immune from reinfection with the virus form that has mutated. Without answers to these questions, we run the risk that people who believe they are immune take fewer precautions and actually become risks for contracting and transmitting the virus. Plus, we don’t know whether the tests we have available that were designed to detect the original virus nucleic acids, antigens or antibodies will detect the new forms of the virus after multiple mutations.

So, after a next wave in late May/early June, I fear a bigger wave in the fall. Although there are important differences between this coronavirus and the flu, past influenza pandemics do give us some important insights into what might happen with this coronavirus pandemic given that coronavirus and influenza are both respiratory viruses and transmitted in similar ways, though there are reasons why the coronavirus is more of a threat due to greater contagiousness, a longer incubation period, a longer period of asymptomatic or pre-symptomatic viral shedding, etc. In several of the past influenza pandemics, a small wave of infection occurred in the early part of the year, as we have just been through, followed by a significantly larger wave about six months later in the fall. This happened with the 1918 – 1919 Spanish flu pandemic and the second wave was much deadlier. There is speculation that the influenza virus may have mutated during the time between the first and second waves. The longer the virus continues to spread, the greater the chance for mutations that will make the virus more contagious and/or more deadly.

I fear we could see this happen. And, unfortunately, late fall is also when we see the resurgence of other respiratory viruses, so it may be harder to detect COVID cases, as it was at the beginning of this year. I fear that this means cities like New York, New Orleans, and Seattle could be in for an even larger outbreak of this virus than they have just been getting behind them, and I am sure that this is unimaginable for them.

Of course, it is also possible that Americans will sustain their efforts at social distancing and good hand hygiene for the next year or years until we do have a vaccine or achieve herd immunity through natural infection. This could mean that we have ongoing waves, but of low amplitude that do not overwhelm our health care system and do not disrupt our lives as much as happened over the past couple of months. On the other hand, I fear that the SARS-CoV-2 virus might mutate enough to evade our immune systems so that it becomes a recurring seasonal infection much like influenza, and even if we have a vaccine, we may need to get periodic vaccines to adjust to new strains of the virus.

Obviously, effective therapeutic options that taken early might prevent serious illness and deaths and/or an effective vaccine would be game changers and allow me to remove many of these concerns from my top 25 list.

Until then, I encourage Americans not to let our guard down and our federal and state governments and local hospitals and health systems to use this time of relative recovery over the summer to prepare for a potential second wave in the coming weeks and a potentially severe third wave this fall. 

Here is the most frequent question I get. It goes something like this. The virus isn’t going away. We can’t stop it without a vaccine and that could be a very long time, and our economy cannot be shut down that long. The only way to slow it down is to achieve herd immunity. We know who is most vulnerable, so why don’t we just keep the elderly and those with serious medical conditions home and get everyone else back to work so that we restore the economy and get to herd immunity?

It is a very insightful question. So, let’s dig in.

First of all, I want to commend the many who have come to the realization that it is very unlikely that this virus is going away anytime soon. Everyone has seen the various models shown on cable and on the internet showing a bell-shaped curve that seems to magically end sometime this summer. These graphs and depictions are terribly misleading. Those really only portray the first wave of this pandemic, and most all experts agree that there will be more waves coming, though it is uncertain how many and what their magnitude will be.

SARS-CoV-2 is an RNA virus and RNA viruses do tend to mutate frequently, and this virus has already mutated a number of times. It is possible that it could mutate and become less infectious or transmissible, and this happened to some degree in the case of the first SARS virus, but this is something we can hope for, but should not anticipate. This would be the only scenario I can think of where the models I referred to above could be right.

Let me also commend the growing number of people who are understanding what herd immunity is. This is the level of immunity in a population required to significantly impair the transmission of the virus. Herd immunity does not mean that a person within the herd (the community) cannot become infected, but it means that the chances are significantly reduced because so many in the herd have immunity that there is no longer efficient transmission of the virus. In other words, there might be isolated cases, but we would be unlikely to see an outbreak of disease in that population.

Herd immunity protects infants who have not yet had the infection and who may be too young to receive a vaccine and it protects those that are high risk, such as those who are elderly and might have waning immunity or those who are immunocompromised and may not be eligible for or protected by a vaccine.

The more contagious a virus is, the higher the level of herd immunity that will be required. For example, the reproduction number (an indicator of how many people someone infected is likely to infect without mitigation in a vulnerable population) is about 6 times higher for measles than it appears to be for COVID. Therefore, herd immunity for measles likely requires that 93-95 percent of the population be immune, either by vaccination or prior infection in order to achieve herd immunity. Mumps has a reproductive number about 5 times that for COVID, and it is estimated that about 90 – 92 percent of a population needs to be immune to prevent spread of mumps to susceptible individuals in that population. For this particular virus, we don’t yet know the level of immunity necessary in a population to slow down the transmission, but projections are in the 60 – 70 percent range.

In Brazil, there was an outbreak of Zika virus. After two years, about 63% of Brazilians had natural immunity (i.e., they had previously been infected and developed immunity to reinfection). This was a high enough percentage of Brazil’s population that the viral spread burned itself out.

With polio on the other hand, a vaccine was developed that was highly effective, and a sufficient number of the world’s population was immunized that polio has essentially been eliminated except from two countries that do not immunize their populations (Afghanistan and Pakistan).

So, now back to the question I get asked. Since a vaccine is not in sight and we know the high-risk populations, why don’t we keep the high-risk individuals at home and get everyone else back to school or work and let’s get to 60 – 70 percent of the population infected so that we have herd immunity?

For illustrative purposes, let’s consider the U.S. a herd. It isn’t because for your purposes, it is the community or population with which you interact and come into contact so it might be quite a bit smaller, but assuming that we want to think about travelling and coming into contact with others at U.S. airports, taking the kids and grandkids to Disneyland, going to sporting events where people from different states are coming together for competitions, visiting other cities and staying in their hotels and going to their restaurants, etc., let’s just look at the United States. (keep in mind that something like 80 million international travelers come to the U.S. each year, so those cities in the U.S. that have disproportionate numbers of international visitors such as Washington D.C., New York City, Los Angeles and Las Vegas may still have outbreaks of disease even if they otherwise have herd immunity, if a sufficient number of these travelers are not also immune. Take for example, McCall, Idaho. Its population can double over the summer months due to visitors and persons with second homes. This could significantly dilute the McCall’s herd immunity if these visitors come from areas that have not achieved herd immunity).

Let’s also assume that we don’t really intend to sentence our seniors to isolation from family, friends and all other contacts for what could be the remainder of their lives until a vaccine does become available. Instead, if we consider the elderly as part of the herd and that we want the herd immunity to give them added protection so that they, too, can return to some semblance of normalcy, though they still may need to exercise precautions, then we will include seniors in the denominator of our total population for achieving 60 – 70 percent immunity. Keep in mind that in our long-term facilities, where many elderly residents have died, it is likely that the exposure of these residents to COVID was through visitors, and more likely, through caregivers who were in contact with others, became infected and then spread the virus to the residents.

The population of the United States is approximately 326.7 million people. Let’s use 2/3rds of the population for the herd immunity threshold. The number of Americans that would have to be infected to reach the herd immunity threshold would be almost 219 million. We don’t really know the case fatality rate for COVID because we do not know how many people have been infected, but even considering asymptomatic and mild infections, most experts seem to think that the mortality rate is at best 0.5 – 1 percent. So, let’s use 0.75 percent. That means that if only 2/3rds of Americans got infected, approximately 1.6 million would die from COVID. Thus far, the U.S. death count from COVID is 65,735 – only about 4 percent of the total deaths that would occur if we were to get 2/3rds of our population infected to achieve herd immunity. That would mean that the U.S. would experience 1,575,932 more deaths from COVID until we reached the herd immunity threshold.

Now there is a whole lot in between mild illness and death. In other words, the price we would pay for herd immunity is more than just loss of life. There are many who would survive, but would endure a prolonged hospital stay, significant morbidity and disability and a prolonged recovery. Keep in mind that while the elderly are more likely to die, 69% of cases, 55% of hospitalizations, 47% of ICU admissions (and generally, it is about half of these who would be on ventilators), and 20% of deaths occur in those under age 65. Many of these affected would be in the prime of their lives.

Not only could just the illness in individuals under age 65 in some cases overwhelm the health care delivery system and result in significant health care costs for society as a whole, but there would be loss of work force productivity due to illness and subsequent disability. For example, of those who require mechanical ventilation, even prior to COVID, these patients not infrequently suffered from traumatic false memories and even post-traumatic stress disorder. This occurs even with the usual support with a ventilator generally being several days. With COVID, those requiring ventilator support often can require it for one to three weeks. We expect that far more will suffer these long-lasting sequelae, resulting in disability, significant ongoing treatment costs and lost productivity at work.

In addition, we have learned that SARS-CoV-2 is not just a respiratory virus. It can cause systemic disease, and in fact, we are seeing a growing number of cases of kidney failure, major strokes and other vascular consequences in young adults in their 30s and 40s. While this is still a minority of young people, the consequences and disability can be significant in these people who otherwise would be in the prime of their lives.

Without a cure for this disease, or at least a treatment that can prevent the disease from becoming severe, we must continue to take infection control measures to slow down the spread of this virus until the virus burns out, we have effective treatments or we have a vaccine. That doesn’t mean that we have to keep the economy on hold. It just means that we have to adapt. Some of these changes will likely need to stay in place after COVID. We need to abandon the handshake. The culture of schools and businesses needs to change to encourage people to stay home when sick. We need to use technology for virtual meetings, for physician visits, for school and working from home, when feasible. And, no doubt many businesses will operate differently, at least for the next year or two. There will likely be more online services, curbside delivery or appointment-based services with screening of both employees and clients. We have to get as many businesses back open as soon as possible and as safely as possible.

For the reasons above, the answer cannot be full-speed ahead with the economy in an attempt to achieve herd immunity. But, at the same time, the answer also cannot be to shut down the economy for a couple of years to achieve herd immunity through vaccination. We have to strike the right balance between slowing the spread of the virus to a manageable level that does not overwhelm our health care infrastructure or result in more mortality and morbidity than necessary, but yet getting businesses back open and people back to work because there are also many excess health consequences for people who are unemployed, uninsured and unable to access routine health care.

A Tribute to our Public Health Workers

President Trump has made an apt analogy indicating that we are fighting a war against an invisible enemy. My service on the Governor’s Coronavirus Work Group has given me an opportunity to see Idaho’s “invisible army” from behind the scenes. I refer to the amazing men and women who serve in our state’s Department of Health and Welfare and local public health departments.

I refer to them as an invisible army because most Idahoans don’t know who they are or what they do, and are unlikely to interact with them directly. These are incredibly dedicated and passionate experts in their fields who work at our state laboratory, who work as epidemiologists, who trace the contacts of those who become infected, who track disease activity and statistics, who coordinate our responses to public health threats, and who help educate and advise the public and our health care professionals.

These individuals often turn down more lucrative opportunities in the private sector because of their passion for the work of public health and their commitment to being public servants.

I have been amazed at the experience and expertise we have here in Idaho. I cannot tell you how fortunate we are to have these talented individuals who dedicate their careers to promoting the health of Idahoans. We owe them a debt of gratitude.

No test is perfect. We can certainly strive for perfection, but perfection is not a proper criterion for the development or use of a test. As a physician, two golden rules have guided my past practice. Number one, don’t order a test unless you plan to do something different depending on its result (lots of examples where doing a test on a person with low likelihood of a condition led us down a long, and sometimes dangerous, rabbit trail of further testing and procedures that ultimately harmed and did not help the patient). Number two, always understand the limitations of any test you order, to understand what it can tell you, what it doesn’t tell you and how it may be either a false positive (the test says you have a condition, but you don’t) or a false negative (the test says you don’t have a condition, but you do).

Antibody testing for the novel coronavirus is an exciting development and holds great promise in the future (and, I don’t think it is a distant future – I would not be surprised if we got answers to our questions later this year). These tests are new, being studied and we still have many unanswered questions that are critical to be answered before we change our lives based on their results.

A number of people have been touting that antibody testing can “get people back to work and give them back the lives that they were hoping for.” This may very well come true. It is not true today.

So, given a push for antibody testing, but given warnings from others, how should Idaho employers think about whether they should require employees to have antibody tests?

1. If those pushing you to do antibody testing are making false claims, beware. To me, if someone makes false claims, that undermines their credibility. That doesn’t mean they can’t be right about other things, but beware and be extra skeptical. What are some of the false claims I have heard thrown around?
   • That an antibody test is “FDA-approved.” As of today, there are no novel coronavirus antibody tests that are FDA-approved. There are four tests that have received Emergency Use Authorizations (EUA) as of the time of this writing, and then others that are being offered pursuant to notification without an EUA. FDA-approved has a special meaning and implies some rigorous review. EUAs and notifications have not gone through this extensive review.
   • That a test is “100% accurate”. I cannot think of a single test we have that is 100% accurate. We don’t require and shouldn’t require 100% accuracy in making medical decisions, but like the old saying, “if something sounds too good to be true, it probably is.” Again, this doesn’t mean that a test being pushed is not a good test, but it is one more thing I weigh when I am considering the credibility of someone trying to get me to buy or do something. As, a physician, I have never ordered a test that is 100% accurate, but I know what the limitations to a test are that I am doing and I advise my patients accordingly when I explain their test result to them.
   • The test has 100% sensitivity and 100% specificity. I am not a statistician, but I don’t think this is even possible. You could certainly have a test that is 100% sensitive or 100% specific, but I don’t believe a test could be both. Again, it doesn’t mean it is not a good test, but it is an additional factor to weigh when you consider whether you can trust this particular source of information on the test. Again, I don’t require that a test I order is 100% sensitive and 100% specific, but as the person who will interpret the test and explain it to my patient, I need to understand where the test may suggest my patient has a condition that I don’t think they have or doesn’t have a condition that I think they do have.
2. I am not an expert on immunology or virology, but I do know enough to ask questions and I know when I can’t get answers to my questions or those answers don’t make sense or the answers I get can be fact-checked and readily disproven, that I am going to be a bit distrustful and probably not get reassurance without the advice of experts. Most employers are not going to be experts in these areas, either. So, what can you do?
   • Have your HR or medical advisors check the guidance of the World Health Organization, the CDC or your local public health department. If they are cautioning against taking this step, you should too. Further, the FDA does provide some helpful advice and has issued warnings that you will want to be aware of before using antibody testing for employment-related decisions.
   • Read what experts without conflicts of interest are saying in the press and media.
   • There are many reasons why local experts will not speak out publicly about misinformation. If you do see an expert, or even a non-expert but someone who is knowledgeable, speaking out and expressing concern, you should be extra diligent in asking probing questions and seeking validation of claims being made before you make your own decision as to engage in the testing.
   • Consult with experts, but make sure that these experts do not have conflicts of interest. Some of the biggest proponents of antibody testing for purposes not recommended by authorities and other experts are those who have a conflict of interest and stand to gain by publicity, funding or direct sales of the testing. A conflict of interest does not mean that someone is not being truthful or doesn’t have a great product, but we need to keep in mind that sometimes conflicts of interest do influence how someone portrays a product and may not create the incentives for the person to be fully transparent and give all the necessary qualifications for their statements. We just need to do extra diligence when someone is asking us to change a practice or buy something when we know that they stand to gain from those decisions.
   • Realizing that I am not an expert and likely your business does not have expertise in this area, it may not be prudent to enter into a debate with someone who professes to be over the facts or the science behind the test. Instead, my biggest flashing red light goes off when someone recommends something that they themselves are not doing. So, four simple questions to ask the person pushing the test.
     1. Do you or your company benefit in any way if people purchase the testing you are advocating?
     2. If a doctor or a clinic are promoting an antibody test as a way to “get people back to work and give them back the lives that they were hoping for,” then I would ask them to show you the evidence that they are using the antibody test for themselves and their employees for that purpose. If someone tests negative, do they not permit them to come to work or care for patients who potentially have COVID? If the physician or employee does test positive, are they allowing the person to be put in higher risk situations than those who test negative? Are you imposing a lower level of infection prevention procedures for those who test positive? Are you prioritizing PPE to those who test negative and relaxing the PPE protections for those who test positive? After each question, ask why or why not.
     3. Most often, insurance companies do not provide coverage for tests that are not proven and that are used for purposes that the government does not approve of. I would ask, which insurance companies are providing coverage for this testing and if so, can you provide me with the evidence?
     4. In those cases where someone suggests that a test is perfect and is 100% accurate, I would ask then why hasn’t the FDA approved it (when you are told that it is FDA-approved, ask for them to show you that evidence from the FDA) and why are the WHO, CDC and State public health authorities recommending against it instead of actively promoting the test?
3. As I mentioned at the beginning of my blog post, I don’t order a test unless it may change my management of a patient. Otherwise, why would you put the patient through the discomfort of the test, the time associated with getting the test, the risks that a test may cause and the cost of the test? So, I would ask the same thing of employers. If you are requiring your employees to get a test, then answer the following questions for yourself:
   • What will I do differently if my employee tests positive? Will I put them in higher risk activities than those who test negative? Will I try to conserve PPE or other equipment and lessen the protection that I offer to these employees? If you are not going to change their work assignment or change their protection or procedures, why are you spending the money for a test, assuming that you are either paying for your employee to be tested or your company’s health plan is?
   • What will I do differently if my employee tests negative? By the way, unless your company provides health care, we think (we don’t know, but this could be an area where the use of antibody testing could be useful) that at most, 10 percent of Idahoans have been infected. Many think it could be considerably lower. So, if at least 90 percent of your workforce has a negative antibody test, does that mean you are not going to allow them back to work? Are you going to take additional safety measures if you do allow them to return to work? If you aren’t going to do anything different, why are you putting your employees through the time, effort and potentially cost of getting tested?
   • If my company decides not to allow persons who test negative to return to work, what liability are we assuming for potential employee discrimination or other claims related to conditioning the ability to work on a test that is not approved by the FDA or supported for this use by health authorities? Obviously, liability could be minimized by continuing to pay employees who you don’t allow to return to work, but can you sustain this? Can you run your business with less than 10 percent of your workforce? And, to the extent you furlough employees without pay who are not testing positive, could employees ultimately become so desperate that they decide to purposefully put themselves as risk in an attempt to become infected and subsequently have a passing test that will allow them to return to work?
4. Finally, just as a physician would, an employer requiring a test or using the test to make employment-related decisions should ask themselves, what does a positive test mean? Unfortunately, most lay persons believe that a positive antibody test means they are immune. We have reason to believe that is likely to be the case and we certainly hope that is true, but we simply don’t know and anyone who tells you that they can assure you that your employees are immune based solely on the results of this antibody test should be added to the list of people you remain skeptical of. We may have the evidence before long that this may indeed be true. But, it would be reckless to make that assumption today. Just ask that person if they tested positive, would they be willing to take a direct challenge with the virus to confirm they are immune?

I understand that we want to reopen the economy and get back to work. I want the same thing. Ironically, I am proposing that people get back to work sooner at lower cost than those who are proposing we use the antibody testing to get back to work. What we do know is that the infection prevention recommendations work – social distancing, covering coughs and sneezes, washing hands, working form home when feasible, avoid non-essential travel, avoiding large groups of people, wear a face covering out in public, etc.

I am saying that if your business is open or can open and you can implement these measures, bring your employees back to work today. And, I have been saying this since April 15. There is no reason that your employees need to wait until they can schedule an antibody test, get to a clinic that can get the sample, send the sample to an out-of-state lab, get the results back and there is no reason that you or the employee need to incur these costs. If they can work today with a positive antibody test, they could have been working since April 15 without the antibody test. I can’t imagine what an employer or the employee should do differently whether they have a positive or negative antibody test. (Well, actually I can, but it means keeping the antibody positive person off work longer – note, there is a period of time when people are possibly still shedding virus after they start producing IgG. In fact, knowing that the employee is IgG positive and allowing them to return to work immediately, may also create liability.)

Obviously, this is a fast-changing environment. We are learning more about the virus and making technological advances every day. At some point in the near future, my advice is likely to change – when we can get accurate facts and have the data to support those facts. In the meantime, let’s not spend money that we are not going to get value for, and let’s not imagine that these tests tell us something they don’t and inadvertently put people at risk of serious, and sadly sometimes fatal, illness.

 Well, the first step is to see if any of your insurance policies provide for business interruption or business disruption coverage. It is certainly possible that you have a separate policy for business interruption, but not infrequently, this may be covered under an overall comprehensive coverage policy or as part of a property/casualty policy. It could be covered as part of a rider to one of these policies, or in rare situations, you might have a specific policy for an infectious outbreak or pandemic event (a so-called bespoke policy).

If you have an insurance broker, ask your broker for assistance in reviewing your policies to see if you have business interruption or disruption coverage and the answers to the questions below. If you don’t have a broker, speak with your business’ attorney.

Step 1. Determine what kind of coverage you have. For purposes of this blog post, I am going to assume the most common situation, that if you have coverage, it is part of a property/casualty insurance policy. We are going to look at the potential for at least four ways that you might be able to claim coverage. The first is business interruption. The problem is that if this is part of a property/casualty policy, the coverage is likely tailored to damage to the policyholder’s own property. This can present a couple of problems. First, does coronavirus qualify as damage to the property? Second, if the business is renting the property and does not have its own policy, the business may not be covered under the landlord’s policy.

The second potential source of coverage is contingent business interruption coverage. That will ordinarily mean interruption to a supplier’s business that then limited your own, but could also extend to a loss of customers. As an example, one could imagine that a food processor might have had to cut down production because they could not get access to face masks and gloves that were being redirected to health care providers and this in turn might have reduced deliveries to a restaurant or store that then lost sales volume due to decreased shipments of certain items they depend on. With respect to a loss of customers, one could imagine that a business that provides event planning services that suffers losses due to the prohibitions on gatherings of more than ten people.

A third source of coverage, which would be very important in the case that your business could have gone on just fine, did not have property damage and your supply chain remain intact, but you had to close or reduce your business because of the governor’s order and this provision in a policy is often referred to as an order of civil authority. An interesting declaratory action case has been filed – Cajun Conti, LLC et al. v. Certain Underwriters at Lloyd’s, London et al. in the Civil District Court for the Parish of Orleans, State of Louisiana- in which a restaurant is seeking the court’s ruling that closure pursuant to the Governor’s order will trigger coverage under the company’s business interruption insurance. A decision will not be binding on courts in other jurisdictions, but it may nevertheless be instructive, and perhaps even persuasive.

Finally, even if your business remained open, did not suffer any “property damage,” was able to continue getting the supplies it needed, and was not shuttered by an order of civil authority, it might still be covered if this business is one that depends on patrons from a nearby business that was shuttered (a so-called leader property) and there is a provision in the policy that may be referred to as Loss of Attraction, or something similar. An example might be a private bookstore that is located adjacent to a college or university and typically sells books and college-themed apparel to the students of the college or university that is now closed for the remainder of the school year.

If your policies don’t cover any of these, then you are likely out of luck, but be sure to consult with your insurance broker or attorney just to make sure.

Step 2. If you do have one or more of these coverages, then determine what is the event that triggers coverage. Most often, if the business interruption coverage is under your property/casualty policy, the critical question will be whether you incurred property damage. If you are fortunate that you have a separate business interruption policy or bespoke policy that covers an infectious outbreak or pandemic, then often the triggering event will be the date that the infection became reportable to authorities. In the U.S., that was January 8, 2020. If you have coverage for an order of civil authority and your business operates in Idaho, that date would be March 25, 2020.

But, in most cases, the question is was there property damage. The key question will be whether the mere presence of coronavirus constitutes property damage. While coronavirus does not cause damage in the typical sense, the virus may be present in the air handling system or on surfaces in the business. There are legal cases where the courts have decided that the presence of a harmful substance does constitute property damage. This may be an easier case to make if you have had workers documented to have become infected. Essential businesses, where there is an ongoing threat of the virus being present in the business may be in the best position to prevail on this point. (But even if the business can prevail on this point, the bigger hurdle is the next step).

Step 3. Check for exclusions. This is not the first epidemic or pandemic. Insurance companies have been aware of the likelihood of another pandemic for some time, and many modified their policies many years ago to exclude pandemics and other public health threats. Read your policy carefully. There may very well be an exclusion.

Step 4. If you do have coverage, then you need to look at the policy to determine what is exactly covered. For example, coverage may be limited to certain types of costs such as the cost to sanitize your business or with opening up an alternative location for your business and might not cover your lost revenues or profits. Additionally, even if you have broad coverage, the amount you can recover may be subject to a cap.

So, this all is very complicated. Be sure to read your policy because every policy is different and every business’ impact from this pandemic may be different. Reach out to your insurance broker or business attorney for help to understand if you are covered, what you are covered for and deadlines by which you need to submit your claim.

This is also a time to review what your coverage is and if you want to change it for the future. Keep in mind the factors above and discuss this with your insurance broker. Unfortunately, the occurrence of this pandemic is not likely to result in insurance coverage that is more expansive or lower cost, but to the extent that any carriers will still offer coverage for these events, you may want to consider whether it is worth it to you to pay more to get at least some coverage for a future event.

Life is tough enough when everything is going relatively well. But, at a time like this, with fear, uncertainty, loss of autonomy, a decrease in our social interactions, an endless news cycle of bad news, and financial hardship, anyone can be vulnerable to depression, anxiety, suicidal thoughts or a relapse for alcoholics or drug addicts.

So, I asked my sister, a psychiatrist and chief of psychiatry at a hospital in the Texas Medical Center in Houston to write this guest blog piece to provide you with advice on how to care for your mental health during a time like this. We want you to know that you are important, your life is valuable and there are many people who care about you. The bravest thing you can do is to ask for help if you need it.

So, here is my sister, Dr. Jennifer Pate, who I am very proud of, with her advice to all my blog readers.

Let’s face it, these tiny red fuzz balls have impacted every aspect of life down to the last square of toilet paper.  Many of you have families or friends directly impacted and we are here to let you know we care and support you.

I appreciate my brother Dr. David Pate allowing me to guest post.

As a psychiatrist, I am receiving many calls from distraught or suicidal patients, especially those living alone.  Please reach out to your single friends who live alone.  This is especially important for our seniors.  Many seniors who are otherwise quite functional are struggling and becoming confused due to lack of stimulation in isolation.  We can all relate to the fact that days seem like weeks and weeks seem like years. I remember days on a cruise ship (of all places) where they would announce the day and date.  We should do the same especially at senior living facilities where people cant leave their rooms to lessen confusion.

Make sure that you are not overusing your meds.  You may think it is okay to take one or two more pills, but it may not be safe to do that.

In a post where I am trying to perk you up, this topic may seem odd.  Make this an opportunity to update your medication list in the event you are hospitalized and even more importantly, update your advance directives.  Have a conversation with your family about what you would and would not want with regards to a trial on a ventilator, dialysis, and other medical care.  Please, understand that you are never having to choose to “pull the plug”, you are verbalizing what your family member is unable to articulate.  You should know what is wanted from having had a conversation BEFORE the crisis.

This is an excellent opportunity to write your obituary, plan your funeral and inventory all financial accounts and passwords. Our father wrote his obituary and just left the date off and this is a gift I appreciate daily.   Make sure you and your spouse know where all financial accounts are and passwords for the accounts.

This is an opportunity to organize and spring clean.  Perhaps you have never had time to clean out that closet and now you do.

Maintain a routine.  Try to sleep and get up at normal hours.

Exercise is a known antidepressant.  Take advantage of each day with weather allowing you to get outside.

If you are struggling with child abuse or domestic violence, reach out to community resources.

I have had multiple suicidal patients this week.  Please reach out to the suicide hotlines.  If you need to be seen, try to go to a free-standing mental health facility and not a hospital ER.  There are many therapists online and you can explore options at PsychologyToday.com.

People in recovery from alcohol or drugs are incredibly prone to relapse.  Contact AA Intergroup to connect with online meetings.

Limit your exposure to media coverage as that may be traumatizing as well.  I tell my patients to chose two sessions of news daily.  One in the morning and one in the evening.  Otherwise sign up with your favorite news outlet and receive notifications on your phone regarding any urgent news.

If you are healthy and live in a low risk household, offer to get groceries or run errands for those who can’t.

Our shelter pets need us, too.  Many shelters are allowing you to apply online to foster.  You then pull up to the shelter and they load the foster pet in your car.  We all know the many health benefits of pets.

Stay safe, Stay sane and thank you for following the stay at home orders to protect all of us!

We are all better together apart!

If you are suicidal or thinking about suicide, call your doctor or call the national suicide prevention lifeline at 1-800-273-8255.

If you or someone you know is being abused, get help as soon as possible. You can cal the Idaho Legal Aid Service’s domestic violence hotline at 208-746-7541.

For AA meeting locations and times, call 1-844-334-6862.

Today, Idaho’s governor Brad Little announced his much-awaited decision as to the fate of his March 25, 2020 order to stay-in-place that would have expired tonight at midnight. His decision was to extend the current order until April 30 and to amend it to include three new provisions:

1. Anyone traveling to Idaho from out of state other than those coming to seek medical attention, must self-isolate for 14 days;
2. Non-essential businesses that can re-open and sell their services or products by curbside, drive-in, drive-through, mail or delivery can do so; and
3. Those non-essential businesses that cannot re-open safely can still undertake efforts to sanitize their facilities, order personal protective equipment, make policies and procedures to implement social distancing, and otherwise prepare for an eventual reopening.

What does this mean:

1. Idahoans have done a great job with social distancing, washing our hands, working from home, restricting our travel, etc. It has flattened the curve, but flattening the curve does not mean it is over or there is no longer a threat.
2. We can’t give up now. Our efforts have undoubtedly saved lives and prevented us from overwhelming our hospitals. The more cases of COVID we prevent, the fewer times we expose our health care workers. While the Governor has made a great compromise to allow more Idahoans to get back to work and to help our businesses recover, the truth is that the virus is not gone, the overwhelming majority of Idahoans remain susceptible and letting up on our infection control practices will simply cause a new wave of infections, hospitalizations and deaths.

This leads to a lot of questions:

1. When will we be able to get back to normal?

This is the most difficult question. The only thing I am relatively certain about is that it won’t be this summer, as it seems most of the White House briefings and tv pundits seem to suggest.

Everyone has seen the models on the internet and on tv that show a bell curve and show that the number of cases comes down to zero sometime over the summer. I just can’t figure out why. I can only think of four reasons that could possibly happen, and I don’t think any of them are likely. First, the virus could mutate in such a way that it no longer is transmitted efficiently. That is possible. RNA viruses such as the coronavirus do mutate fairly frequently, but generally not to the degree of changing its fundamental nature. So, yes, that could occur, but it would not be reasonable for us to plan on it.

Second, we could develop a medication that if taken at the onset of symptoms might prevent the illness from becoming severe, requiring hospitalization or causing death. Again, possible, but I don’t think we should be planning on that.

Third, we could have so many people who become infected that we develop so-called herd immunity, which means that there are so few susceptible individuals that the virus cannot efficiently be transmitted. We are not sure what percent of the population would have to be infected to achieve herd immunity through natural infection, but virologists seem to think it is more than 50 – 60%, and perhaps in excess of 80%. I simply cannot imagine the scenario by which more than half of all Idahoans are infected by this summer. Our hospitals would be overwhelmed and the death count would be horrible.

Fourth, we achieve herd immunity, not through natural infection, but by vaccination. However, no one believes that the vaccine can be ready in less than a year, and that is if everything goes perfectly.

So, I think we will be dealing this virus for the next year or two. Certainly, not at the level we have been, and most likely in ebbs and flows, but it seems some level of continued social distancing will be necessary until we have a vaccine and can immunize a sufficient percentage of the population.

• Can we just test people for the virus and if they are negative, allow them to return to work?

No. The test for the virus is a test that you have seen on tv where a healthcare worker sticks a swab way back into someone’s nose. There are now some other ways to get the sample for this test. It is a test that identifies portions of the virus. The presence of virus is often used as an indicator of infection, but the presence of virus does not necessarily mean infection.

Nevertheless, even if a test were negative today, that wouldn’t mean someone would not be infectious the next day. The test’s best use is to look for evidence of the virus in the setting of symptoms consistent with COVID-19. It simply is not a practical method to screen a workforce that is asymptomatic to determine who might be infected.

• Can we screen employees for antibodies and then if positive, allow those persons to return to work without the need for social distancing and personal protective equipment?

Not yet. There is only one antibody test that has received an Emergency Use Authorization from the FDA, and that was just a little over a week ago. An Emergency Use Authorization (“EUA”) is not the same thing as being FDA approved.  An EUA is issued when there is an urgent need for the product, but we don’t yet know its effectiveness. The EUA allows a new product to be put to use and requires that as it is used, the manufacturer will submit data to the FDA that will allow it to determine its effectiveness. So, first of all, the antibody test is not yet widely available. Second, we don’t know whether a positive test might result as a result of cross-reactivity with the ordinary coronaviruses that people have been exposed to, and therefore might not be specific for this novel coronavirus infection. Even if a positive test does mean that the person is or was infected with coronavirus, we don’t know whether that means that the person is immune to subsequent infection with the coronavirus, and if so, for how long?

We are fighting a war, and while doing so it can be difficult to look forward into the future. Right now, we are just trying to decide when will this disease “peak,” level off and decline and when is it safe to relax restrictions that have been placed on Americans.

But, for the purposes of this blog post, I want to look beyond this pandemic. One day, this pandemic will be history. And, as the oft quoted saying goes, “those who do not learn history are doomed to repeat it.” We must be bold enough to admit that there are many opportunities for improvement and we must capture those soon, and put improvements in place, before life returns too much back to normal and this is no longer at the top of our consciousness. The following are the conclusions I think we need to come to, and then at then end, I will list my recommendations:

1. Let’s stop saying that no one could have foreseen this. I understand that the public at large never imagined this, but scientists, health care experts and the government have contemplated this kind of event for nearly two decades (and not only have we had other pandemics, we have had a number of close calls), and the realization of such a threat is very well documented. This is not our first pandemic, and I hate to tell you, but this will not be our last. If we can stop talking about this like it is unimaginable or some kind of fluke event, we can start preparing for the next one. We will then have the opportunity to avoid some of the loss of life and damage to the world’s economies that we are experiencing now.  
2. Let’s also not pretend that this health crisis has been led and managed perfectly and the outcome we are suffering could not have been avoided to some extent. If we don’t, then we will not take advantage of all the lessons that can be learned to improve our response the next time. To just reinforce my point, there will be a next time, perhaps not in my lifetime, but I cannot imagine there will not be another pandemic, or at least epidemic posing the risk of a pandemic, in my children’s or grandchildren’s lives.
3. Let’s admit that we were not prepared. This is not about Trump-bashing. Let me be clear, no president in modern history has been prepared for the kinds of disasters that scientists, health care experts and even members of their own administrations have warned them about. It seems to me that one of the failings of having public health and disaster planning under the President and subject to his budget is that politicians are generally not rewarded for major long-term investments that their constituents cannot feel the benefit of and that may only pay off when they are no longer in office.
4. Let’s realize that we were slow to act in a day and age that requires a much faster response to a pandemic threat than before we were a global society and economy. And, this is always likely to be the case as long as the decision to act will be under the direction of a politician, and it is hard to fault them. No one wants to be criticized for “overreacting.” But, in a world where more than 115 million people travel internationally a day and about 320,000 people arrive to the U.S. every day from other countries, it is not hard to see how quickly an infectious disease can spread across the world, when the doubling time of an infection is measured in days.
5. Let’s also realize that we need the cooperation of the world to adequately defend against these threats. We all need to share public health and medical information real-time. This is probably a good time for us to reach international agreement on this. Further, any time we identify a “novel” virus, as we did on January 10, 2020, this must be our highest level and quickest response from all over the world. A “novel” virus means (1) we don’t know who has the infection, (2) who can transmit the infection, (3) how the infection is transmitted, (4) whether someone can be infected yet asymptomatic, (5) whether someone who is asymptomatic (or more likely, pre-symptomatic) can transmit the virus, (6) how long it takes to develop symptoms once someone is infected, (7) how deadly the virus is, (8) how to contain the virus and prevent its spread, (9) how to prevent health care workers from being infected, and (10) how to treat someone infected with the virus. Thus, when we first detect an outbreak of a novel virus, we must have the world’s agreement that we are going to shut that area of the world down immediately. No one travels in or out of that area until we can answer a good number of these questions.

Just to emphasize this point, in the time between we knew that there was an outbreak of infection with a novel virus until the time we restricted travel from China to the U.S., we likely had more than 6 million travelers arrive in the U.S. from foreign countries. Even with the restriction, we were allowing people from China to return to the U.S. if they were residents without knowing yet that perhaps 20% of those who are infected are asymptomatic and yet, contagious. Thus, temperature screening of travelers turned out not to be an effective way to prevent someone from inadvertently bringing the infection into the U.S.

Now, in full transparency, I have no proof that even a full lock-down by the time we become aware of an outbreak with a novel virus would be fast enough to contain the outbreak. There is still likely to have been travel by the time we realize this is a new type of infection. Nevertheless, it seems likely if we can limit the number of people coming into the U.S. who are infected, perhaps we can slow down the spread and give us additional time to prepare and develop our testing capabilities.

If we can agree on some or most of the above, here are my recommendations:

1. When we get to a more stable situation, we need to have a neutral party (someone who does not have to worry about political embarrassment or grandstanding) do a comprehensive review of the preparation and response, including the successes and missed opportunities of the White House, the CDC, FEMA and all levels of the federal government, the state governments, local governments and health care providers. We must capture best practices to embed in our pandemic plans for the future, as well as learn from the challenges and failures we experienced so as to make them less likely in the future. The party doing this study should also document the lessons learned from the successes and failures of the WHO and other countries.
2. When this review is completed, we need to bring together those who were involved in the management of the COVID response from the Trump administration and from state governments, as well as leaders involved in public health and disaster planning from past administrations, pandemic experts from the government, academic and private sectors; and members of Congress to review the findings, prepare a new pandemic plan for the future and identify the changes in government structure, function and funding required to prepare us for the next threat.
3. We should also bring the WHO and the world’s leaders together to share lessons learned and to develop better systems to monitor the world for new health threats and to better coordinate the world’s response to these threats. This should begin with pressure on China from all the world’s governments and the WHO to outlaw the wet markets, where exotic animals are kept in close proximity and sold for consumption. We have now had two novel coronaviruses that previously were limited to animals, but spread to humans from China and very likely from these markets. This is no longer a China issue; this is a world health issue.
4. As I mentioned above, the world’s response to a novel virus must be swift and much more drastic than in the past. Before, we could not contemplate a situation where we would implement a strict travel ban, not allowing citizens to return home for a period of time. However, we have now seen first-hand that the consequence is relatively fast spread to most of the countries of the world. I am not suggesting that U.S. citizens remain trapped overseas, but rather that anyone in the area of an outbreak with a novel virus remain there until the home government can provide for safe travel home that protects others from possible spread of the infection and a period of isolation or quarantine upon arrival home to the U.S. until we can learn enough about the infection to ensure that the likelihood that they will transmit it to their families, co-workers and others is very low.
5. The plan for the next pandemic needs to be clear about roles and responsibilities. I, and I think most of my colleagues who are health care leaders, thought that the federal government was well-prepared for this scenario, including ample supplies in the Strategic National Stockpile. That proved not to be the case. Most of us were shocked when we heard the White House tell physicians, hospitals and health systems that we should rely on our traditional supply chains, not the federal government or the Strategic National Stockpile. Our traditional supply chains were broken. There was hoarding, price gouging and limitations on supplies and equipment that we could purchase, even if providers were willing to pay the asking price. Further, this meant that hospitals were negotiating and competing for supplies with other hospitals, states, the federal government and the approximately 160 other countries who were all trying to buy supplies. Further, we learned that over the years, budgets for the Strategic National Stockpile and maintenance of equipment in the Stockpile had been reduced, and, as a consequence, most of what was available could only be directed to the several states who were in most need.
6. The plan for the next pandemic must provide for multiple sources of tests and supplies, not just the CDC. The sole reliance on the CDC to develop the test for the coronavirus meant that there was no back-up plan if something went wrong, and something did go wrong. This led to serious delays and a missed opportunity for containment strategies. Further, we need to appreciate that having a test is only as good as the ability to ramp up testing capacity, attain testing reagents, attain testing supplies that are needed to obtain specimens and personal protective equipment (PPE) to protect health care workers in obtaining the specimen from a patient.
7. Every disaster the U.S. has ever responded to has required private industry. The U.S. simply does not have all the resources needed under control of the government. Yet, we have to acknowledge that private industry, while we have seen numerous acts of amazing community support, often acts according to economic incentives. As an example, many companies that were producing badly needed equipment and supplies for the American heath system, were at the same time exporting these goods to other countries who were in need. I am certainly not suggesting that we should not help other countries. However, before we do, we must ensure that we have Americans taken care of. This in of itself would be a good reason to use the powers of the Defense Production Act. Further, we are more than four months into this pandemic and we still have health care providers who do not have sufficient PPE, medications, ventilators, testing reagents, and testing supplies. As a consequence, we cannot be sure who is infected and who is not, which causes us to utilize more PPE than we ordinarily would and unfortunately, we have had many health care workers exposed or infected, which can further compromise our response to this health crisis. We are just now getting rapid testing deployed to some areas of the country. But, until recently, it was not unusual to not have test results back for 7 – 10 days, a situation that further compromises our ability to respond to a public health threat effectively. My point being that in the future, we should be far quicker and more aggressive in utilizing the authority under the Defense Production Act. Americans would understandably be upset if we sent our young men and women into war without an adequate supply of uniforms, bullet-proof vests, weapons and ammunition, tanks, etc., but that is in essence exactly what has happened with our health care workers as we have sent them in to fight this war against an invisible invader.
8. We have seen first hand how important it is to have real-time data on numbers of new cases, hospital admissions, ICU admissions, number of patients on ventilators, deaths, days of supplies on hand, etc. Much of this has required reporting by hospitals and laboratories to their states, the CDC and many other agencies and systems that need this data. Let’s take this opportunity to see how much of this we can automate, so that we don’t have to recreate it for the next health emergency, and let’s look at the opportunity to utilize artificial intelligence so that perhaps this can augment our disease surveillance and reporting for other infectious diseases that we deal with annually or even year-round, even when we are not dealing with a pandemic.
9. Finally, we need to have a difficult conversation about how we manage a disease outbreak within the U.S. At the time the U.S. was imposing a travel ban on persons from Ireland travelling to the U.S., NYC actually had more confirmed cases than Ireland did. People debate the wisdom and effectiveness of travel bans. I get it. However, even those who argue against them seem to agree that it can slow down the spread of an infectious disease. That is what the U.S. needed – more time. More time to better understand the virus, to study potential therapeutic options, to develop a vaccine and to prevent our hospitals from becoming overwhelmed. So, should we implement travel restrictions within the U.S.? Ask those towns that are ski resorts. Almost all of them have significantly higher numbers of cases of COVID than other parts of the U.S. Why? People who were infected elsewhere and did not realize it, traveled to these resorts and transmitted the virus to others.

I’m sure I will have more about this in future blog posts, but I think this is an important discussion for us to have as a country.

I want to express my admiration for our health care professionals – doctors, physician assistants, nurse practitioners, nurses, respiratory therapists, radiology technicians, pharmacists, infection control practitioners, laboratory technologists, nursing and medical assistants and everyone else involved in caring for our patients, as well as those who make it possible for them to provide that care – environmental services workers, supply chain professionals, food service workers, security, health care leaders, those who serve as reception and registration staff, and everyone else who contributes to the operations of our urgent care centers, emergency departments and hospitals.

Think about how scared you have been hearing about the sickness and death caused by this pandemic. Now imagine caring for these patients, seeing the shocking rapid deterioration of a patient in his or her 30s or 40s who was talking to you yesterday, but sedated and paralyzed on a ventilator today. Think about being that nurse, alone with a patient, holding their hand as the patient takes his or her last breath.

Health care professionals are scared too. We are scared when we don’t totally understand a communicable disease and aren’t convinced we have the ability to prevent ourselves from becoming infected. It doesn’t help when we hear about our colleagues who have been infected or died, or in dreadful situations, where we have to put a breathing tube into someone we were working along side just last week.

Though we get scared too, I have never known of a situation where one of us did not come to work willing to take the chance that we might become sick, because, like law enforcement and first responders, it is our calling, our duty, and our passion to care for others. More often, what wears on us is not the concern that we might become ill, or perhaps even die, it is the concern for our families – that we might inadvertently bring this disease home to one of our family members. That is far worse in our minds.

So, I want to take this opportunity to tell all those who show up to work at urgent care centers and hospitals in the midst of this pandemic – you inspire me. I am extremely proud of you, and I can never thank you enough for your courage, your dedication and your talents. I pray for your health and safety every day.

President Trump was right – we are fighting a war against an invisible enemy – the novel coronavirus. In this case our health care professionals are the soldiers in this fight. Therefore, I ask the President to provide recognition to health care workers who die of this disease during their courageous service to win this war in a manner analogous to how we honor fallen soldiers. And, when we do win this war, I would ask the President’s consideration of a national day of celebrating our health care heroes and honoring the memory of those health care workers who give their own lives to save the lives of others.

God bless all these brave men and women.