A Cancer Doc Reflects on COVID Response: How the System Held

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Nearly 18 months ago, I came home after a brief trip to Nepal to participate in a cancer conference sponsored by the Binaytara Foundation (BTF) and to witness firsthand the remarkable work of humanitarians Binay Shah and his wife, Tara. They had been working tirelessly (and as I later witnessed, remarkably effectively), to create more equitable cancer care for people of Janakpur Nepal. I had written about this experience in an early post in the blog.

While in Nepal, my attention was focused each day on the work of the BTF, but when I retreated to my room each night, I would read what I could about the emerging Coronavirus epidemic. I was horrified how quickly the virus had swept through Wuhan, China as well as Lombardy, Italy. It seemed inevitable that SARS-CoV-2 would also cause havoc and death in the US.

Following a medical career that has been largely focused for three decades on the needs of people living with HIV and those with cancer, I was struck by several similarities between the virus that caused AIDS and the virus that caused COVID-19. Beginning in 1979 there was uncertainty how HIV was transmitted, and there was great fear in treating those who suffered from AIDS. Back then, the level of misinformation spread by both the media and our public institutions was staggering and that misinformation helped intensify and perpetuate significant societal and familial fissures between the LGBTQ+ community and their families. Those divisions were to remain large for years to come, and while circumstances are better today, it would be naïve of me to imply that problem has been solved.

That first weekend back from Nepal, I went into work to catch up on paperwork and to clear email. It was clear that infection-control practices were just beginning to take shape in the wake of the Coronavirus. As I passed our first-floor pharmacy, I noticed a large collection of patients, all of whom were huddled closely together while waiting in queue to pick up their prescriptions. There was no dividing plexiglass shield between patients and pharmacists, and not all folks were wearing masks. I sent an email to our leadership group calling attention to several glaring deficits, unsure how this information would be received.

I was concerned that basic rules of cleanliness which we now take for granted were not yet enacted within our hospital. I also took pictures of our clinic office spaces which were in the same state of disarray as they had been before my trip to Nepal. I then showed them to our nurse leadership so we could develop a hygiene plan for our oncology clinic ASAP, starting with physician offices and exam rooms as well as high-volume central patient check-in and waiting areas. I also began pestering our medical directors to change our many in-person meetings to virtual ones to limit our risk of COVID-19 exposure.

Rules were hastily and imperfectly enacted to prevent spread of Coronavirus within our hospitals and to protect patients and staff. Patients with COVID-19 infections were cared for in isolation rooms and the sickest were dying alone without the comfort of beloved family members at their side. Years earlier, those with HIV were also dying alone. Then, it had more to do with antipathy toward a relatively small group of people who had chosen a different path to live their lives. It was healthcare professionals who specialized in HIV care who so compassionately filled that void. More often, they served as community for those who were close to death and ensured that people with advanced HIV infection did not die alone.

Before effective antiviral medications, healthcare workers were uncertain whether personal protective equipment would be available to safely carry out daily chores and while caring intimately for those with HIV infection. During my residency at UCLA Medical Center several of my colleagues were pregnant or were planning to become pregnant and were given the option not to care for those with HIV.

I was reminded of this after my closest friend and a physician at New York Hospital sent me a slide set from a talk by an infectious disease physician from China that detailed the measures implemented in Wuhan hospitals to control COVID-19. The containment plans of our Chinese counterparts were startlingly efficient and reminded me of scenes from The Andromeda Strain, a bestselling novel written decades ago by Michael Crichton. It provided an apocalyptic view of a virus run amok and the desperate efforts of scientists to control its spread. In the movie, as in China, patients were quarantined, hospital quarters were pristine and sterile, and the use of personal protective equipment meant the physicians and nurses were unrecognizable while moving eerily between one bed to the next.

As COVID-19 began dominating news coverage, I was mystified by the tepid response of our public health institutions—most notably the CDC—as well as that of the President. As reported recently in the Washington Post, the Trump administration repeatedly interfered with efforts by the CDC last year to issue warnings and guidance about the evolving coronavirus pandemic. Our President was strangely intent on politicizing simple infection control measures. At each public forum, his refusal to don a mask became a misguided symbol of defiance rather than a practical way to limit infections and deaths. Trump was also fueling racial tensions, particularly through his persistent and inaccurate characterization of the novel Coronavirus of 2019 as “the China virus.” I worried over the impact Trump’s divisive and corrosive rhetoric would have in accelerating racial tensions against Asians and other minorities.

His references to SARS-CoV-2 as a simple virus, no more concerning than the common flu, also served to trivialize the lives already lost to the virus and seemed targeted to those who were disproportionately impacted by the first deadly wave of COVID-19 infections. Admittedly, at that time, I did not foresee how the toxic effects of the virus and the weird mix of politics and social media would quickly bubble to the top. Nor could I have imagined the role that social media would play in dividing our country and culminating in the storming of the Capitol on November 6, 2021.

Concerns for contagion, previously viewed largely as theoretical, became a personal and urgent when one of our oncology colleagues and his wife became ill with COVID-19. Days earlier, that doctor had met with our hematologists, oncologists, and pathology and radiology colleagues to review and discuss cancer cases at our weekly hematology-pathology tumor board. We were all bunched together in a tiny room with no windows.

By luck or by grace of God, a super-spreader event did not take place as it did just a few weeks later among a Marysville church choir group. At that event, at least 52 people were infected with COVID-19 and several later died from COVID-19 complications. Concerns for aerosolization of tiny viral laden particles as well as the more obvious infectious risks of larger droplets could no longer be dismissed as science fiction.

I felt oddly removed and powerless as sad stories of people whose lives were cut short by COVID-19 became a daily occurrence. I started cutting and pasting articles about COVID-19 from credible sources and forwarding them to family and colleagues with small commentaries. I was concerned how social media was being used to twist facts about the virus and promulgate hate and fuel paranoia.

There were many uncertainties, but my experiences in the HIV era provided me a perspective that a newer generation of healthcare providers and administrators lacked. In the earliest days of the Coronavirus pandemic, it was easy for me to see the importance that virtual medical visits would take once patients stopped coming to clinic because of fear of contagion. I also appreciated the potential role of COVID vaccines which could perhaps promote herd immunity and hopefully be more effective that those used to limit HIV infection.  Yet, quite honestly, it never occurred to me that I would still be writing about Coronavirus infection 18 months later. I also admit that I did not envision a virus that would kill more than 750,000 Americans and 5 million additional people worldwide.

Another challenge that I did not anticipate was the impact of COVID-19 on our healthcare system. Several months into the pandemic, The Seattle Times ran a story that the University of Washington Medical Center had lost $500 million. I mistakenly thought that my institution, because it was smaller and thus more agile, was in a better position to withstand the winds of change that were blowing over healthcare. But within a month, our leaders conceded that Virginia Mason had lost $46 million in a similar time span, and Virginia Mason was forced to furlough healthcare workers and implement pay cuts.

I also did not foresee the impact the pandemic would have on this country’s workforce. COVID-19 has altered the way Americans think about work, underpinning what many call “The Great Resignation.” The Bureau of Labor Statistics announced that 4.3 million Americans quit their jobs in August. That’s 2.9% of the entire US workforce, a record-breaking figure. Unfortunately the healthcare industry is no exception to this trend.

Among ICU nurses of all ages, two-thirds have considered leaving the profession because of the pandemic, according to a survey published in September by the American Association of Critical-Care Nurses. This figure also reflects the realities of nurses at our downtown cancer center and clinic. Nearly every month for the past year, our division has held a going away party for yet another nurse working in hematology and oncology. When a nurse leaves—whether to retire, become a travel nurse, or work in another field—the remaining nurses can be stretched dangerously thin, caring for more patients at once. This is as true for highly trained oncology nurses as it is for critical care nurses.

And the exodus of personnel is not confined to our nurses. Roomers, schedulers, and other people on whom we depend to provide seamless care have also left. The exodus of valuable coworkers has a profoundly dispiriting effect on those who remain and who, by necessity, shoulder more responsibility with progressively fewer resources with which to complete their work.

The findings of a survey published last month by Morning Consult illustrate how the drop out in employees affects healthcare workers. Most notably, 79 percent of healthcare professionals said that the national shortage of employees has impacted them, stretching them to their limits with more patients to handle and fewer colleagues to offer support. Many survey respondents said their workload has increased, resulting in rushed or lower-quality care for patients. Almost one-in-five respondents reported disapproval over how their employers had handled the pandemic, citing “poor communication around changing safety protocols, inadequate personal protective equipment, low pay, and a general sense of being disposable.”

While the pandemic has exacerbated the rate of resignations, staff shortages were already an issue prior to COVID-19. According to a report published by NPR, decades of stagnant pay are also partially to blame. But the impacts of the pandemic—including childcare demands, business closures, and fear of the virus itself—also play a role. When trusted and experienced workers such as that nurse leave the system, the loss cannot be quantified but is profound.

Although there are many lessons to learn from the pandemic it is important to take solace and comfort when we can. One such pleasure for me is to have my son Jake help me on the blog. Jake has a degree in digital arts and serves as editor. Over time, he has become quite a stern task master. He occasionally fact-checks statements, suggests additions, and redirects me when I stray too far off-topic. He also lays out the blog with his considerable artistic eye. This blog would not be possible without his efforts and help.

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Dr. Aboulafia is a member of the Division of Hematology and Oncology at Virginia Mason where he has worked for three decades. He is a Clinical Professor of medicine at the University of Washington and a principle investigator for the National Cancer Institute funded group The AIDS Malignancy Consortium. He has a career-long interest in HIV as well as the link between certain viruses and cancer.

1 COMMENT

  1. Doctor, this is a story well told. Thanks to you and your son Jake for contributing. As a layperson, I found your account easy to follow even for those of us not part of the medical profession. Because I am so admiring, I hesitate but feel compelled to mention that the date of the storming of the U.S. Capitol is incorrect. That despicable event took place January 6, 2021, not in November. Forgive me for quibbling when so much else was valuable.
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