COVID-19: FROM THE FRONT LINES

The news from Italy, along with the mounting number of new cases in the US, has everyone scrambling to figure out what to do about the coronavirus. Three weeks ago, Italy had only 17 cases, which turned into 7,000 cases with 350 people dead by this past Sunday. On the front lines of health care locally, community health center leaders are developing detailed plans, informed by advice from the Centers for Disease Control and Prevention, the Department of Public Health, and the Boston Public Health Commission.

The problem is that much remains unclear as of this writing (March 9), and most are waiting to see which way this virus goes.

The Bloomberg Coronavirus Daily posed the question of whether the US will go the way of Singapore or Italy. Singapore was a likely location for an outbreak due to its close geographic and economic ties to China, but took decisive measures, such as aggressive testing, tracking, and quarantining, with the result that they have had only 150 cases. Italy waited. Its health care system is straining to meet clinical needs from infected patients and the entire country of 60 million people is in lockdown.

What we can expect in Boston is anyone’s guess, but there is evidence that our country’s pattern will likely follow Italy’s. Many of the newer cases have no obvious relationship to previous cases, which would imply that there are carriers who may be asymptomatic who are infecting others without knowing they’re infected. The goal then, at least for now, needs to be to slow the infection rate down so that it can be managed.

So, from the perspective of a neighborhood health center, what can be done? These centers are the primary care providers (PCP) for about a million Massachusetts residents. Sick patients will go to health center urgent care centers, which means that the number one goal for health centers is to ensure that their clinicians are healthy. The nightmare scenario is that coronavirus infects a health center’s staff and they have to be quarantined, which then limits access to care during a health crisis. Unfortunately, there is a shortage of Personal Protective Equipment (including masks) for medical providers, due to a run on these items.

Health center administrators are figuring out appropriate staffing needs based on how bad the epidemic may get, and looking at ways to increase urgent care access if needed. Health centers are increasing cleaning and infection control measures, limiting group meetings, using their electronic visit notification systems to educate patients about what to do and not to do, and changing their interactions with patients to include questions that could help identify cases.

In addition to educating their patients, health centers also have a public health responsibility for their communities. They can publicize the standard steps to avoid a virus – wash your hands, don’t touch your face, cough into your elbow, stay home when sick, and more cleaning at your home – through their networks and electronic messaging.

Essentially, we need to identify people with the virus, provide care for those who need it, quarantine those who don’t for two weeks, and hope that we can stop the spread. But our burden is made greater by our growing reliance on what is called a gig economy, in which workers have no benefits, and so, no sick time. Will a person driving an Uber self-quarantine for two weeks with no income? We also have a serious problem providing enough test kits to identify those carrying the virus.

So far, Massachusetts health centers have gotten a minimal number of test kits. If someone comes into a health center with symptoms after perhaps recent travel to a virus cluster area, providers need to call DPH for permission to provide the test. While there may be a good reason for this, the result may mean delays in addition to already insufficient testing.

Hopefully, this will be resolved quickly, and there will be enough tests for anyone who needs one, and that may include far more people than those with a fever, cough, and recent foreign travel. The really scary thing is that we do not know how many people have the virus. We know that there are a number of asymptomatic people who are carrying it, but we don’t know what that number is.

The Chinese are providing 1.5 million tests a week; South Korea has devised a “drive through” testing system and provided 180,000 tests. Meanwhile, our government has shipped 75,000 tests, our Center for Disease Control had counted 1,583 tests as of March 9, and our president is calling the coronavirus a hoax. This is not the way to run a first world health care system.

Bill Walczak, a Savin Hill resident, was the head of the Codman Square Health Center for close to 40 years and a former president of the Carney Hospital.