“You go to war with the army you have, not the army you might want or wish to have at a later time.” –Donald Rumsfeld.
The same is true of our healthcare system. In this article I will not attempt to keep up with headline news. Instead I want to focus on three issues: history, organizational resilience, and some predictions about issues not being widely discussed, yet.
Some 15 years ago, I read John Barry’s history of the paradigm of the deadly pandemic—the 1918-1919 influenza epidemic. While it is a worthwhile read, there are more readily available Internet resources which summarize the data. When I read the book, I was acutely aware that my grandfather was an active duty physician in the U. S. Army and that he was dealing with this epidemic. Re-reading it, it is clear, too, that our playbook is essentially the same—isolation, containment, social distancing, etc. In the future will be population testing and probably some sort of vaccine and perhaps anti-viral therapeutics, but for now treatment is supportive. While the full scope of the current SARS-CoV-2 epidemic remains to be defined, it looks as though it will be more like the 1918 influenza epidemic than some of the other epidemics we have endured. Consequently, both individuals and healthcare organizations, and all of society will experience stress. Getting through this will take resilience at both a personal and a group level.
I was a practicing nephrologist when HIV infection became a new blood-borne pathogen. Since there were no laboratory tests that were reliable or timely, the CDC recommended dialysis staff go to “universal precautions.” While some staff resisted making the change, at least a couple quit their jobs due to the danger. Today we are seeing people reporting what they are experiencing and complaining about a lack of adequate supplies, particularly personal protective equipment, all of which is predictable.
I don’t mean to suggest the complaints aren’t real—I am sure they are. But in all fairness, it is a predictable based on where we were. Do you remember “lean processes?” How about “supply chain management?” Administrators were being told that to remain profitable they had to get waste out of their processes, and most have been trying as hard as they can to do so. But that means the suppliers are also under pressure. There is no incentive to over-produce surgical masks, for instance, if there is nothing to do but place them on the shelf. However, resilient organizations will find ways to do work arounds, like acquiring cloth masks from their public, until manufacturers can catch up with the surge in demand. In the meantime, both providers and their support staffs are experiencing stress.
Many of these issues are raised by Hick and Biddinger in an article published online 25 March 2020 in the New England Journal of Medicine. They conclude:
“Why do we assume that a healthcare system that must run at maximal efficiency and full occupancy to survive will, without additional support, suddenly be able to meet the needs of all in a crisis? Why we do not have caches of inexpensive volume-cycled ventilators with basic alarm systems?
Because we fail to learn the lessons and dedicate the funding and planning efforts required. Because doing so is not prioritized by regulators, payers, or most hospital leaders. Because the need is not understood by the public. Because you can’t rely on private-sector infrastructure to take on a massive public responsibility in disasters without proper planning and resources.”
Conscientious hospital leaders, who take their responsibilities to their public and their staff seriously are facing a moral challenge—how do you act responsibly in a crisis without endangering the survival of the entire organization. In my area many rural hospitals have already closed and the ones that are left have few to no staff for more than emergency care. We have a lot more bed capacity than we have staff capable of using them.
Physicians will also face a moral challenge. We are accustomed to assuming it is our job to do “everything” for a patient, but in a time of crisis we will need to modify that to “everything we can within the limits of the resources on hand.” The military system of triage is based on managing limited resources and deploying them to those most likely to benefit (survive). Having to live with this for a prolonged period will be stressful.
Nacoti and associates, working in Bergamo, Italy, where the crisis has been severe and prolonged, make this point.
“Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care. What we are painfully learning is that we need experts in public health and epidemics, yet this has not been the focus of decision makers at the national, regional, and hospital levels. We lack expertise on epidemic conditions, guiding us to adopt special measures to reduce epidemiologically negative behaviors.”
What we should remember through all this, though, is that some care is better than no care, and sometimes simple nursing care can make a difference. Let me illustrate this with a hopeful story from an earlier epidemic. My father told the story of being home visiting his grandmother about 1929 when he found photographs of children in distorted postures. His aunt discovered him looking at the pictures and took them away but told them his father had received a “rising vote of thanks from the Georgia Legislature” for what he did. His father never talked about it and Dad did not know “the rest of the story” until 2013, when I found an article from The Atlanta Constitution made it clear.
In the spring of 1913, one hundred years before, Atlanta experienced a major outbreak of meningococcal meningitis. Grady Hospital, then as now the major public hospital, opened a temporary contagion hospital to isolate infected patients. Dr. Lucius F. Wright, Sr., Dr. L. L. Blair, Mrs. Mamie Ashford, and Miss Annie Butler volunteered to be isolated in the ward. They were interviewed by telephone for the article after being there about a month. By then the ward had treated 38 patients, only three of whom died (8%), all within the first 30 hours of their admission. Given there were no effective therapies for meningococcal meningitis then, the results show that good care helps.
The newspaper reporter emphasized the infection was contagious and asked them what they were doing to avoid getting meningitis themselves. They replied: “Eight percent cleanliness, two percent caution, two percent sterilization, and eighty eight percent trust in Providence.” The formula for dealing with the risk is probably as valid today as it was in 1913.
29 March 2020
 https://www.goodreads.com/quotes/1215538-you-go-to-war-with-the-army-you-have-not. Accessed 26 March 2020.
 Barry, John M. The Great Influenza: The Story of the Deadliest Pandemic in History. (New York, Viking Penguin, 2004.)
 Billings M., The Influenza Pandemic of 1918 June 1997, modified RDS February 2005. https://virus.stanford.edu/uda/index.html. The Public Health Response. https://virus.stanford.edu/uda/fluresponse.html. Cf. also https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html, March 20, 2019. All accessed 24 March 2020.
 Jester B, Uyeki T, Jernigan D. Readiness for Responding to a Severe Pandemic 100 Years After 1918. Am J. Epidemiology 2018;187(12):2596-2602.
 I saw a post today where some tinkerers at Vanderbilt took off the shelf windshield wiper parts and some boards and made a simple device to operate an Ambu-bag.
 Hick JL, Biddinger PD. Novel Coronavirus and Old Lessons—Preparing the Health System for the Pandemic. doi. 10.1056/NEJMp2005118. Accessed at NEJM.org, 25 March 2020.
 Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Naspro R, Longhi L, Cereda M., Montaguti C. NEJM Catalyst, 21 March 2020. doi. 10.1056/CAT.20.0080. Accessed at NEJM.org, 27 March 2020.
 The Atlanta Constitution, Sunday, 4 May 1913, p. 37. Copy located online at Ancestry.com.
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