A public health update on COVID-19 [PODCAST]

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“Over the last 100 years, the U.S. has had to respond to five avian flu pandemics. The most severe was the 1918 avian influenza infecting 1/3 of the world’s population and killing 650,000 Americans. It was also the last time wide-spread containment, mitigation, and isolation strategies were used in the U.S. Seldom mentioned about the 1918 pandemic are the three ‘waves’ or cycles of resurgence and the subsequent deaths associated with them, especially in cities and towns that failed to implement timely mitigation restrictions or rescinded them too quickly.

When considering the rescindment of mitigation restrictions, a bottom-to-top approach (local-state-federal governments) must be followed precisely to account for the kinetics of the virus. It is the virus that will truly dictate when American lives can return to some semblance of normal. The goal is to taper restrictions to avoid a cycle of new COVID-19 outbreaks and thus minimize the similar cycle of deaths, which followed in the 1918 pandemic.”

Nicolas K. Fletcher is a public health student.

He shares his story and discusses his KevinMD article, “Strategies for lifting COVID-19 mitigation restrictions.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Nicolas Fletcher. He’s a health policy student, and he recently wrote the KevinMD article “Strategies for lifting COVID-19 mitigation restrictions.” We’re filming this in the last week of June, so his post is certainly very relevant. First off, Nicolas, welcome to the show.

Nicolas K. Fletcher: Thank you, Kevin. It’s a pleasure to be here, and like I said earlier, it’s an honor, and I really look forward to our conversation.

Kevin Pho: All right. So before we get into your article, if you could share your story and your journey to where you are today with my audience, that’d be great.

Nicolas K. Fletcher: Sure. So I am originally from South Jersey. I grew up in a regular middle-class family. I went to college, undergrad, at Howard University in Washington, D.C., graduated in ’01, and I worked for a number of years in the biotech sector, kind of following the human genome model after we were able to map the genome. A lot of biotech companies spun off of that, and I worked for eight years as a research associate and associate scientist doing drug development research for lupus, HIV vaccine research, and rheumatoid arthritis.

From there, I kind of had, like most people, that existential question of what am I supposed to do with my life, around 27, 28. And I decided that was as good a time as any to really go back and follow my dream, which was to go to medical school, get into medical school, and become a physician. And so I went back to school. I took the MCATs more than once, and I matriculated into the Michigan State University College of Human Medicine, their post-bachelor program. I did that for two years, and then I was fortunate enough to matriculate into the medical school, graduating in 2017.

Kevin Pho: Fantastic. So with the pandemic going on, and you’re a health policy student, this is right up your alley. So we’ll talk about your article, “Strategies for lifting COVID-19 mitigation restrictions.” So, why did you share the story behind that article?

Nicolas K. Fletcher: Yeah. So for me, part of it was born out of just being a health policy student at the moment, but then it also was my interpretation of answering questions that weren’t being asked by our state, local, and national leadership. I felt like people were very much focused on COVID-19 at the time; testing was becoming an issue. But nobody was really addressing what we do after that six months, I mean, the four weeks or six weeks or 12 weeks. There was this humongous question of, OK, what is the next normal supposed to look like if we don’t have treatment or don’t have a vaccine? How are we, as a collective, supposed to be able to move forward confidently and continue to do the things we need to do in order to outlast what is a global pandemic? And to me, I felt I needed to answer that question, and in answering that question, that’s how the article came out.

Kevin Pho: So let’s go to that article. In an ideal world, what is your strategy for lifting those mitigation restrictions?

Nicolas K. Fletcher: For me, I think it’s very, very important that people have access to knowledge, and that includes knowing where to get tested when they need to be tested and knowing that their hospital systems are able to handle the capacity. Because I think a lot of people forget that it’s not just COVID-19 patients that are in hospitals. Most hospitals are already at 50, 60 percent capacity on any given day, and when you add a surge of patients as complicated as COVID-19 patients, you now not only see those beds occupied, those beds are also occupied for much longer than your average patient. And so that puts a strain on the health system in your local community.

And if they’re not ready to handle that type of patient population, then that impacts those who are in need of care for a femur fracture, or those who just have a childhood upper respiratory infection, or anything else. And that is without people absolutely understanding that just because they don’t have COVID-19 doesn’t mean that they’re not going to be impacted in their community.

And so, again, knowing where to go to get tested, knowing your hospital system can handle it, and also getting the information that you need in a timely manner from the people that are in the know, such as your local health care provider, your local county health care providers, the government, the local government, the mayor, all the way up and down the chain. And so getting that information in a timely manner, knowing where to get tested, and knowing your hospital system can handle it, I think, are some of the most important things. And it sounds really basic, but at the same time, you don’t have to listen to the news or read anything long enough to realize that those things aren’t in place.

Kevin Pho: Yeah. Why don’t we go into more analysis on that? Because you wrote this strategy back at the end of April, and we are now talking in the last week of June. Can you give your analysis on the current situation as it relates to the pandemic?

Nicolas K. Fletcher: Yeah. So my article was written pretty much looking past that first wave of the pandemic, the notion that, OK, there’s this very steep increase in the number of cases and number of hospitalizations, but then you’re going to see it, isn’t, eventually come down. And the flattening of the curve, as people were trying to get to, is more based on the social distancing that needed to be in place. As long as people were respecting that social distancing, the mask wearing, and things of that nature, that is what leads to a decrease in those numbers.

But unfortunately, I don’t personally believe we’re even past that first wave, that first surge, because we’re not even into fall, we’re not even into the flu season, and so we’re still in that first wave. Places like New York and New Jersey and Michigan, where I am, saw that wave come through earlier, but now that we’re looking at Texas and Florida and Phoenix, Arizona, and California, again, people are beginning to understand that the kinetics of the virus are going to be what they are. It is the only control, the only standard that we have, in that it’s going to do what it wants to do when it wants to do it. We’re the ones that have to change our behavior. The virus is just going to do what it’s meant to do, which is move from one host to the next as much as it can, as quickly as it can.

Kevin Pho: Like you said, there are outbreaks right now in Texas and Arizona and in Florida, and now even in California. And what needs to happen next? I just heard that the governor of Texas, they’re closing bars. They’re talking about shutting down elective surgeries again. It sounds like we’re going back to where we were in March and April. So if you were in charge of public health policy for this country, what would be your suggestions going forward?

Nicolas K. Fletcher: Testing is absolutely needed. We need to be able to test anywhere from about 6 to 8 percent of the population locally every day, and without being able to do that, we have no idea where the virus is in the community. We have no idea how prevalent the virus is in the community. And so long as we don’t have that information, we’re always playing whack-a-mole, always trying to catch up to where the virus is. We’re not being proactive; we’re being reactive as a community. And that’s going to be the normal, the next normal, until we find a vaccine, or until we develop a vaccine or really good therapeutics that come close to a vaccine.

But until then, if we don’t put these mitigation factors in place that I’ve talked about, the testing, the hospital systems, even antibody testing, finding out if people have it, and if they don’t have it, knowing that they can possibly go back to work or be more responsible about their movements. Without having the basic things in place, because we have nothing else in our arsenal for COVID-19, the only thing that we can do is change our behavior so that we lower the risk from ourselves to others and those around us, and unless people are willing to think about others. I saw a blurb where it showed that the risk of COVID-19 was low, but the fear of contracting COVID-19 was very high in early May, or early March. It’s now switched. The risk with COVID-19 has actually increased dramatically, and people are no longer concerned about themselves or their fellow man and the risk of infection. And so that has to go back to where it was in March, now that the risk of infection is high, and people need to be more aware of their risk of infection.

Kevin Pho: So I want to be realistic, because there is a possibility that we’ll never get to where we want to be when it comes to testing. Everything that we’re using to combat COVID has been politicized; even wearing a mask, of course, has been politicized. So assuming that we’re going on our current trajectory and we don’t have the testing that we need, what’s going to happen in the next three to six months as it relates to the virus?

Nicolas K. Fletcher: Again, the virus is going to do whatever it can to survive. That’s what viruses do. They just move from host to host, and so we’re going to see people continually getting affected. I think we’re going to end up with a leveling of the plateau with infections. We just saw the highest number of infections, I think 33,000 in a day, yesterday or the day before. That number is going to either plateau between now and the fall, and then I believe it’s going to increase when we start seeing flu cases come around and more people are going to be trapped indoors again after having been moving around all summer. And then we’re going to be right back where we were in early March if people do not take this seriously through the summer.

Kevin Pho: And what’s your opinion about schools opening or not in the fall?

Nicolas K. Fletcher: Interesting question. My wife is a psychology professor at K College here in Michigan, and they’re grappling with this very question about what school is supposed to look like in the fall. Again, I’m a student. Fortunately, I’m distance learning, so nothing has really changed for me; the program was pretty much built for this. But I think, especially for college students, it’s going to be incredibly difficult to put them on campus and expect them to social distance the way that they need to.

And so my fear is that unless these institutions have very strong leadership and make it clear to the students, in the same way that governors are saying, “Look, we’re doing the best we can with what we have, and we need you guys to play your part. We need you to lean into this and say we’re going to maintain all the social distance that we can. We’re going to do our best to not socialize to an extent that’s going to lead to some type of super-infection event.”

I think you’re going to see a hybrid model of institutions. Some are looking at decreasing class size, some are looking at going totally online. If I had to say one thing, I would lean towards them trying their best to do some type of distance learning, at least for the fall semester. I know that’s not what people pay for college. That’s not what you want your college to be. But I feel like putting everybody in the dorm for four months and then expecting them to social distance is going to be very difficult. And so I would lean towards more distance learning, I would lean towards smaller class sizes, and I would lean towards anything that can essentially remove the barriers for students being able to do what they need to do to stay safe.

Kevin Pho: We’re talking to Nicolas Fletcher. He’s a health policy student, and he wrote the KevinMD article “Strategies for lifting COVID-19 mitigation restrictions.” He’s given us wonderful insights on the pandemic and perhaps our next three to six months with the pandemic. Nicolas, what’s your take-home message for the KevinMD audience?

Nicolas K. Fletcher: I would say it’s important, especially for the KevinMD audience, that right now, physicians, we really need to be front and center, not just dealing with our COVID patients specifically. I think it’s important that we step forward and speak up for public health and speak up for the importance of public health. I think it has become the scapegoat for the last couple of weeks because of what has become more of a political argument. And I think physicians are strategically placed in the intersection of politics and health, health care delivery, and just interacting with patients, that we need to be able to stand up and say, “OK, this is what we believe our patients and just the general public should be doing to take care of our health moving forward during this pandemic.”

Kevin Pho: Well, thank you so much for sharing your expertise, and thank you for being on the show.

Nicolas K. Fletcher: It was my pleasure. Thank you, Kevin.

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