In the year since Washington state sounded the alarm of the pandemic to the rest of the country, it also served in many ways as a model for how to start getting it under control medically, epidemiologically and socially. “It's really something that had been unimaginable in public health planning and preparedness planning,” Duchin says.
None of the lessons we’ve learned here have been easily won. Most required a great deal of personal sacrifice against the backdrop of 400,000 American lives lost and counting, with more than 4,000 of them in our state.
“We had a perfect storm with a political leadership that fractured the country, and higher levels of lack of trust in government, and no cohesive national health system or a well-funded public health system that is well integrated and coordinated,” Duchin says. “The response was fractured.”
But if we take these lessons in stride, most experts say we’ll be better positioned to tackle the pandemic in its second (and hopefully last) year, despite an ever-growing stream of new challenges.
Big realizations
With millions of people hospitalized and many times more infected, medical and public health professionals have had many opportunities to observe the coronavirus at work and learn the best ways to track, diagnose, treat and prevent it. But its newness meant experts learning about it in real time were always one step behind.
“I walk into [the hospital] every day recognizing that I do not know the answers to many of the questions I’m going to be asked,” says Dr. John Lynch, medical director of the infectious diseases clinic at the University of Washington’s Harborview Medical Center.
Having humility about how unpredictable biology can be helped experts pivot when new information emerged, says Dr. Keith Jerome, head of the UW Virology Lab and a virologist at the Fred Hutchinson Cancer Research Center, who was behind early efforts to start testing in King County.
The big surprises were that the virus can transfer between people, instead of only from animals to humans; that it’s aerosolized and can linger in the air; and that even asymptomatic people can transmit it — unlike with SARS, Jerome says, in which people tend to have more lead time between when they fall ill and when they become infectious.
“It turns out in retrospect, you have all these people who are shedding high levels of virus for a few days before they feel bad. How do you control that? The symptom checks don't work very well, not enough to contain things,” he says. “I think that was the single biggest surprise that we saw here. What this really taught us was it is an absolute race for time to get the diagnosis made.”
Duchin says that knowing earlier about asymptomatic spread would have changed Public Health’s approach to contact tracing. “We also use contact tracing to provide social support to people who need it, for quarantine or to connect them with social services, particularly in disadvantaged communities…. But it’s not the disease control tool that we would like it to be,” he says.
Providence Regional Medical Center’s Dr. George Diaz, section chief for infectious diseases, led the first team in the country to treat a confirmed COVID patient. Without existing medical literature, he and other doctors had to learn through trial and error what kinds of treatments created the best patient outcomes through trial and error.
Some of these lessons are process-oriented: Doctors like Diaz are getting more attuned to how people look when they’re starting to fall sick, they’re not relying on invasive ventilators to keep people breathing, and they’re proning people even when they don’t look critically ill.
Diaz, who still keeps in touch with that first patient over text (he’s doing fine), points to a few critical things doctors have learned that are helpful for patient prognosis. The most important is early diagnosis and treatment — something that early testing delays made difficult, resulting in unnecessary hospital admissions and difficulty admitting patients into clinical trial programs. Hospitals like Providence set up telehealth programs to avoid admitting patients before it was necessary, monitoring patients from home to watch for worsening symptoms before hospitalizing them.
Despite the absence of a strong federal testing plan, early work in the Seattle area made it possible for that testing to get off the ground. And for the past six or seven months, a fairly standardized PCR platform has enabled more diagnoses, Diaz says.
Diaz and colleagues were the first to use remdesiver to treat COVID, setting a standard for National Institutes of Health guidelines. In the past few months, it’s been discovered that steroids like dexamethasone can help treat people with COVID once they’re at the point where they require oxygen; together, those treatments are the current standard of care.
Doctors made these gains while struggling to secure basic medical resources. With most supplies made overseas, Washington’s health care workers struggled to obtain everything from N95 masks to dialysis machines. Hospital administrators figured out how to get new supplies on the fly, with some health care workers finding creative ways to reuse masks and gowns, or even make their own masks. At Providence, the staff have started using reusable gowns, Diaz says.
None of the experts interviewed for this story were prepared for the sheer politicization of science, basic harm reduction materials like masking and even the numbers of cases and deaths, especially at the federal level. They knew there would be divisiveness around public health measures, but not to this extent.
And the spread of misinformation about the virus has public health agencies and hospital systems spending more of their time on countering false narratives. Community members aren’t necessarily learning about the virus from reputable sources.
Over the year, health professionals have been working to bring their messages to “more than the usual suspects,” Diaz says. “There’s been a lot of bravery [among doctors] to go to different news outlets or networks that don't share our views necessarily. I've been put on panel with a doctor that has an opposing view of masks. It doesn't help much to convert the converted, right?”
But some experts said culture within hospitals has changed for the better. Doctors like Lynch say it used to be difficult to get medical professionals on board with infectious disease protocols like hand-washing after touching doorknobs; but the pandemic is increasing compliance and planning across his hospital.
“Hopefully this attention to it will not go away, because we know that the next pandemic is around the corner, potentially, so we have to remain vigilant,” Diaz says.
A second pandemic
COVID wasn’t the only pandemic people contended with this year. Systemic racism exposed long-running social, financial and medical inequities, forcing the medical system and society at large to confront inequity in health care and vaccination planning.
“COVID was just the latest example that those people who experience disparities at baseline due to structural inequities in our society, and not just our health care system, have the worst outcomes,” Duchin says. “What's changed is that we now have energy from the community and renewed commitment from the department and our local leaders to address inequities, because they're very glaring with COVID.”
“It feels like the health systems, the hospitals, medical care [have] entered into the conversation in a way we never ever have before,” Lynch says. “Have we gone far enough? Not by any stretch of the imagination, but the level of dialogue has been building over the past decade, led by many other much more capable people, and it feels like we moved into a different gear this year.”
King County recently declared racism a public health crisis. There are new coalitions and engagement efforts dedicated not only to listening to community members’ concerns and questions, but actively engaging them in the development of pandemic strategies that best help their communities. “We've got faith-based leaders coming together, small businesses, as well as a lot of outreach efforts on the ground with community members themselves,” Duchin says. “So in that sense COVID has sort of reinvigorated the level and intensity of outreach.”
The most frustrating takeaway for Duchin is our failure to learn from history. “Just about every one of these learnings was something that we experienced during H1N1 and was very well described,” he says.
He wrote an article for a National Academies Press publication after the H1N1 flu pandemic in 2009 describing those things that we’d realized are needed to better handle outbreaks: investing in public health, ramping up surveillance systems for sequencing and strains, contact tracing, immunizing, dealing with social problems like misinformation and vaccine hesitancy and the impact of health disparities on Black, Indigenous and people of color communities. “I went back and looked at that article recently and found that just about everything that I had described as a lesson that should be learned was not learned,” Duchin says. “We’re failing the same test twice.”
The challenges ahead
For everything we’ve learned about the virus’s biology, there’s more we don’t know. It’s still unclear why some people get so much sicker than others, which kinds of antiviral medications might be helpful and why people develop some symptoms and not others. Some answers can only come with time — how long natural immune defenses provide protection in recovered COVID patients, or why some patients’ symptoms linger for months.
“Any organ system in the body can be affected by COVID,” Diaz says, “and there are mysteries around what exactly is being triggered. Right now, we're still trying to modulate the immune system so people don’t die.”
The longer this goes on, the more people will require care for long-term symptoms from COVID, which is “clearly a big problem,” Diaz says. He and colleagues have been been referring these types of patients — “long haulers” — to a specialized long-term COVID clinic at Swedish. He looks at telehealth as a “model of the future” to keep these patients monitored and engaged in their health care.
And scarcity of supplies remains an issue for hospitals, testers and beyond.
At UW Medicine, supply-chain employees were looking everywhere for N95 respirators — and it wasn’t until December that they received a reasonable supply, from the gray market, that they had to certify themselves. “We got one big shipment, and that’s all we got,” Lynch says. “We still don’t have that normal supply chain back in shape. We’re always thinking from the perspective of scarcity.”
Without herd immunity, testing continues to be critical. “If you can't test people rapidly and get the results back rapidly, then you're going to be blind to what's going on,” says Diaz.
And while testing groups have ramped up their capacity immensely, investing in instruments, robots and staff, the need for testing continues to grow as case numbers skyrocket, UW virologist Jerome says.
“There's literally thousands more samples that could go through some of these very expensive instruments … but even if we can run them at a quarter capacity, we need those tests,” he says. “Our nation is unable to produce many of the consumables that we actually need for this testing, and it's a concern. We really need to take that to heart.”
Duchin says the state’s vaccine allocation issue is getting worse, and that it’s the most frustrating public health activity he’s ever been involved in.
“Even under the best of circumstances, we were projecting it would not be until summer when most people in the population would have access to vaccines. But it's rolling out even slower than we were led to expect,” Duchin says. “I think in the next few days, with the new administration, we'll have a much better idea of how many doses are actually out there, and what the timeline will be to get the high priority groups and then ultimately everyone vaccinated.”
Vaccination attempts are still hamstrung by the Trump administration’s lack of foresight to invest in not only development, but also distribution — paralleling problems with testing, tracing and resourcing at the federal and state level. “It’s like, OK, we don't have enough tests. We don't have enough PPE [personal protective equipment]. And now, we don't have enough tools to roll out a vaccine. I mean, like, who in the world? There's no one driving the ship. We're just bailing out constantly. And in the dark,” Lynch says.
Washington isn’t on track to meet all of our vaccine targets. Despite moving into Phase 1B, we still haven’t cleared all of the first priority group vaccinations: Inconsistent communication from the federal government about vaccine allocation has made it hard to schedule vaccinations, pharmacies struggled to start vaccinating, and Dr. Scott Lindquist, state epidemiologist for communicable diseases with the Washington State Department of Health, says vaccinating is time intensive — especially for people in elder care facilities, which just finished their first round of vaccinations. The state itself, underfunded for vaccine deployment, has experienced technological difficulties and communication problems around vaccine scheduling.
Lynch is grateful for King County investments in mass vaccination sites, which take some stress off the shoulders of hospitals, but the mass vaccination sites can’t solve everything.
“If we had adequate supplies of vaccine, I would be less concerned … ,” Duchin says. “I would love to be faced with the challenge of having vaccine doses that I need to convince people to take right now. But we've gotten way more people interested in getting vaccine than we have vaccine available.”
New coronavirus variants also have doctors on edge. While Jerome notes the virus mutates “a bit slower” than others, which could help vaccines keep up, its prevalence in the human population could lead to new mutations with unforeseen problems.
“The virus has a lot of shots on goal, so to speak, to come up with a mutation that's advantageous,” he says. “So if we can control the virus better, it would have less chance to mutate.”
Ongoing fatigue
Our health care workforce, though better informed on how to surveil for, test and treat COVID, is hamstrung by trauma and exhaustion.
“I'm worried about the mental health of our workers — not just public health, but hospital workers and clinicians,” Lindquist says. People know how to protect themselves, he says, but “we’re getting community fatigue on these messages, and people just want to be back to some semblance of normal.”
“There's virtually no frontline people that have not been affected by this — there have been sick health care workers, there's been shortages of nursing staff nationwide,” Diaz says. “Burnout is a real issue and concern.”
It’s hard for Lynch to find and hire staff, especially with chaotic vaccine distributions and tight funds. “I can't say, OK, there's a vaccine coming in two weeks or four weeks. I'm going to hire 100 vaccinators. Who's paying for that? It's not like health systems have been doing great this year,” Lynch says. “There are no extra people in health systems. Everyone has a job. And so bringing people in takes time, it takes effort.”
“When you really think about the baseline new normal, excluding mischief with the variance … we're looking at sort of 2022” as when we’ll experience whatever a post-coronavirus sense of normalcy is, he says.
Despite the frustrations, Duchin is encouraged by the Biden administration’s embrace of science and large recent federal investments in the vaccine. “Restoring that primacy of science and public health expertise in the nation's top leadership levels across the country, I think will help us, you know, as a country, move forward in a more productive way to get this behind us quicker,” he says.
Experts like Lindquist stress that there is light at the end of the tunnel.
“We are moving forward. Our death rate in Washington state is half of the national average. Our case rates are much lower than the rest of the country … and we’ve got new tools and some lessons we've learned, so I’m optimistic,” Lindquist says.
“This is not a virus that's uncontrollable, and there are things that we can do to interrupt the spread if we choose to do them,” Duchin says. “They're painful and hard and they come at great cost, but they're preferable to having a million Americans die from this disease.”
