OP-ED: Cancel It if You Can – Taking Responsibility for Controlling the Pandemic

Will Brownsberger is the State Senator for Watertown, Belmont and parts of Boston:

The pandemic will eventually touch many of us. What matters most is the speed of the pandemic. If the virus spreads too fast and too many of us are sick at the same time, we will overwhelm the health care system. People may not be able to get the care they need – for the virus or for any other health problem.  That’s what is starting to happen now in Italy. Doctors are discussing how to make brutal triage decisions effectively condemning weaker patients to die.

We need to slow the virus down and since none of us are immune and there is no vaccine yet, we have only one way to protect our community:  To reduce unnecessary contact. I’m not shaking hands. I’m not calling public meetings. I am reducing my attendance at public meetings. I’m pleased to see so many responsible organizations cancelling public meetings. I’m pleased to see colleges going online. I’m switching most of my private meetings to phone calls. I’m exercising outdoors or at home, not at the gym. I’m not traveling and I’m discouraging family members from traveling. And I’m trying to stay off the MBTA at rush hour. To the extent we have a choice, we all owe it to others to step back and reduce crowding.

As a legislator, I will be part of a team considering all possible responses, including stricter measures to limit spread of the virus. While we may yet dodge the worst scenarios, I am personally convinced that we should be eliminating as many crowd settings as possible. Following health advice from the CDC and our department of public health we can limit risk of infection in one-on-one transactional settings, but in group settings of any size, it is much harder to avoid spreading the disease.

I fully expect that many businesses will be hard hit by the response and I think government has a responsibility to cushion the impact for the workers that are hardest hit. This is the other fundamental public policy challenge we need to contemplate.

Below, I paste a Google translation of a page from an Italian newspaper which published a Facebook post from Dr. Daniele Macchini, a doctor at Humanitas Gavazzeni a hospital in Bergamo, Italy (northeast of Milan). The post was apparently provoked by complaints by people about restrictions on going to the theater and the gym. The post is intended to convey what is stake.

The rough translation, which I have edited lightly for readability, appears below. It deserves a read from beginning to end.

In one of the constant emails that I receive from my health department more than daily now these days, there was also a paragraph entitled “being sociable responsibly”, which made some recommendations that I support. After thinking for a long time if and what to write about what is happening to us, I felt that silence was not at all responsible. I will therefore try to convey to people “not involved in the work” and more distant from our reality, what we are experiencing in Bergamo during these pandemic days from Covid-19. 

I understand the need not to panic. I also understand the economic damage and I am also worried about that. After the epidemic, the tragedy will start again. However, apart from the fact that we are literally also devastating our National Health Service from an economic point of view, I allow myself to raise the importance of the health damage that is likely throughout the country and I find it nothing short of “chilling” for example that a red zone already requested by the region has not yet been established for the municipalities of Alzano Lombardo and Nembro (I would like to clarify that this is pure personal opinion).

I myself looked with some amazement at the reorganizations of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly “emptied”, the elective activities interrupted, the intensive therapies freed to create as many beds as possible. Containers arriving in front of the emergency room to create diversified routes and avoid any infections. All this rapid transformation brought into the corridors of the hospital an atmosphere of surreal silence and emptiness that we still did not understand, waiting for a war that was yet to begin and that many (including me) were not so sure would never come with such ferocity . (All this was done in silence and without publicity.)

I still remember my night watch a week ago that passed anxiously as I waited for a call from the microbiology unit. I was waiting for the outcome of a swab on the first suspect patient in our hospital, thinking about what consequences it would have for us and the clinic. If I think about it, my agitation for one possible case seems almost ridiculous and unjustified, now that I have seen what is happening.

Well, the situation is now nothing short of dramatic. No other words come to mind. The war has literally exploded and the battles are uninterrupted day and night. One after the other the unfortunate poor people come to the emergency room. What they have is nothing like the complications of a flu. Let’s stop saying it’s a bad flu. In these 2 years I have learned that the people of Bergamo do not come to the emergency room without cause. They did well this time too. They followed all the indications given: a week or ten days at home with a fever without going out and risking contagion, but now they can’t take it anymore. They can get enough breath, they need oxygen.

Drug therapies for this virus are few. The course mainly depends on our organism. We can only support it when it can’t take it anymore. It is mainly hoped that our body will eradicate the virus on its own, let’s face it. Antiviral therapies are experimental on this virus and we learn its behavior day after day. Staying at home until the symptoms worsen does not change the prognosis of the disease.

Now, however, that need for beds in all its drama has arrived. One after another, the departments that had been emptied are filling up at an impressive rate. The display boards with the names of the sick, of different colors depending on the operating unit they belong to, are now all red and instead of the surgical operation there is the diagnosis, which is always the same cursed: bilateral interstitial pneumonia.

Now, tell me which flu virus causes such a rapid tragedy. Because that’s the difference (now I’m going down a bit in the technical field): in classical flu, apart from infecting much less of the population over several months, cases can be complicated less frequently, only when the VIRUS destroying the protective barriers of the our respiratory tract allowing BACTERIA normally resident in the upper tract to invade the bronchi and lungs, causing more serious cases. Covid 19 is mild in many young people, but in many elderly people (and not only) it causes a real Sudden Acute Respiratory Syndrome because it arrives directly in the alveoli of the lungs and infects them making them unable to perform their function.

Sorry, but to me as a doctor it shouldn’t reassure you that the most serious are mainly elderly people with other pathologies. The elderly population is the most represented in our country and it is difficult to find someone who, above 65 years of age, does not take at least the tablet for pressure or diabetes. I also assure you that when you see young people who end up in intubated intensive care, pronated or worse in ECMO (a machine for the worst cases, which extracts the blood, re-oxygenates it and returns it to the body, waiting for the organism, hopefully, heal its lungs), any comfort you might take from being young passes then and there.

And while there are still people on social networks who pride themselves on not being afraid by ignoring the indications, protesting that their normal lifestyle habits are “temporarily” in crisis, the epidemiological disaster is taking place. And there are no more surgeons, urologists, orthopedists. We are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us. The cases multiply, we arrive at the rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing.

Emergency provisions are issued: help is needed in the emergency room. A quick meeting to learn how the first aid management software works and a few minutes later they are already downstairs, next to the warriors on the war front. The screen of the PC with the reasons for the access is always the same: fever and respiratory difficulty, fever and cough, respiratory insufficiency etc … Exams, radiology always with the same sentence: bilateral interstitial pneumonia, bilateral interstitial pneumonia, bilateral interstitial pneumonia. All to be hospitalized. Someone already to intubate and go to intensive care. For others it is too late …

Intensive care becomes saturated, and where intensive care ends, more are created. Each ventilator becomes like gold: those of the operating rooms that have now suspended their non-urgent activity become places for intensive care that did not exist before. I found it incredible, or at least I can speak for Humanitas Gavazzeni (where I work) how it was possible to put in place in such a short time a deployment and a reorganization of resources so finely designed to prepare for a disaster of this magnitude. And every reorganization of beds, departments, staff, work shifts and tasks is constantly reviewed day after day to try to give everything and even more.

Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted. I saw fatigue on faces that didn’t know what fatigue was despite the already grueling workloads they had. I have seen people still stop beyond the times they used to stop already, for overtime that was now habitual. I saw solidarity from all of us, who never failed to go to our internist colleagues to ask “what can I do for you now?” or “leave alone that shelter that I think of it.” Doctors who move beds and transfer patients, who administer therapies instead of nurses. Nurses with tears in their eyes because we are unable to save everyone and the vital signs of several patients at the same time reveal an already marked destiny.

There are no more shifts, schedules. Social life is suspended for us. I have been separated for a few months, and I assure you that I have always done everything possible to constantly see my son even on the days of taking the night off, without sleeping and postponing sleep until when I am without him, but for almost 2 weeks I have voluntarily avoided my son nor my family members for fear of infecting them and in turn infecting an elderly grandmother or relatives with other health problems. I’m happy with some photos of my son that I regard between tears and a few video calls.

So be patient too, you can’t go to the theater, museums or gym. Try to have mercy on that myriad of older people you could exterminate. It is not your fault, I know, but of those who put it in your head that you are exaggerating and even this testimony may seem just an exaggeration for those who are far from the epidemic, but please, listen to us, try to leave the house only to indispensable things. Do not go en masse to stock up in supermarkets: it is the worst thing because you concentrate and the risk of contacts with infected people who do not know they are higher. You can go there as you usually do. Maybe if you have a normal mask (even those that are used to do certain manual work) put it on. Don’t look for disease masks. Those should serve us and we are beginning to struggle to find them. By now we have had to optimize their use only in certain circumstances, as the WHO recently suggested in view of their almost ubiquitous impoverishment.

Oh yes, thanks to the shortage of certain devices, I and many other colleagues are certainly exposed despite all the means of protection we have. Some of us have already become infected despite the protocols. Some infected colleagues in turn have infected family members and some of their family members already struggle between life and death. We are where your fears could make you stay away. Try to make sure you stay away. Tell your elderly or other family members to stay indoors. Bring him the groceries please.

We have no alternative. It’s our job. In fact, what I do these days is not really the job I’m used to, but I do it anyway and I will like it as long as it responds to the same principles: try to make some sick people feel better and heal, or even just alleviate the suffering and the pain to those who unfortunately cannot heal.

On the other hand, I don’t spend a lot of words about the people who call us heroes these days and who until yesterday were ready to insult and report us. Both will return to insult and report as soon as everything is over. People forget everything quickly. And we’re not even heroes these days. It’s our job. We risked something bad every day before: when we put our hands in a belly full of blood of someone we don’t even know if he has HIV or hepatitis C; when we do it even though we know it has HIV or hepatitis C; when we sting with the one with HIV and take the drugs that make us vomit from morning to night for a month. When we open with the usual anguish the results of the tests at the various checks after an accidental puncture hoping not to be infected. We simply earn our living with something that gives us emotions. It doesn’t matter if they are beautiful or ugly, just take them home.

In the end we only try to make ourselves useful for everyone. Now try to do it too though: with our actions we influence the life and death of a few dozen people. You with yours, many more. Please share and share the message. We must spread the word to prevent what is happening here in Italy.
L’Eco Di Bergamo, March 8, 2020, translation from Google Translate, lightly edited for readibility.

To the point of what the epidemic means to health care workers, a doctor just sent on this note from another doctor at MGH who is in touch with doctors in Italy .

More deaths among doctors and nurses in Italy- now so many healthcare workers home with pneumonia or symptoms (a few with ARDS intubated in ICU). The president of the Lombardy region of Medicine (something like the Mass AMA President) just passed away this morning for COVID-19. He had symptoms yesterday, intubated at night and cardiac arrest few hours later. He was a PCP and kept working for directing people either to the hospital or keeping them home.  

The great lesson from Italy to protect healthcare workers was the lack of identifying ahead of time areas in the hospital strictly devoted to COVID-19 patients and sending COVID patients in different parts of the hospitals so that many healthcare providers got infected and eventually quarantined jeopardizing functionality of the units/departments and loading of extra-work to those non-infected. Centralization of these patients is key. They have now COVID-only hospitals for hosting those 6,000+ and more in hospital patients in the city of Milan (of which 400+ intubated with ARDS).

There is no other challenge remotely as serious before us as legislators. I hope that we are able to rise to it. In the Senate, we are already taking the internal measures that we can to control the spread and are working with the House to appropriate initial funds to support the response. But there is much more to do.