Category Archives: Pandemic

BANKS PRESSURE HEALTH CARE FIRMS TO RAISE PRICES ON CRITICAL DRUGS, MEDICAL SUPPLIES FOR CORONAVIRUS

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Banks Pressure Health Care Firms to Raise Prices on Critical Drugs, Medical Supplies for Coronavirus

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IN RECENT WEEKS, investment bankers have pressed health care companies on the front lines of fighting the novel coronavirus, including drug firms developing experimental treatments and medical supply firms, to consider ways that they can profit from the crisis.

The media has mostly focused on individuals who have taken advantage of the market for now-scarce medical and hygiene supplies to hoard masks and hand sanitizer and resell them at higher prices. But the largest voices in the health care industry stand to gain from billions of dollars in emergency spending on the pandemic, as do the bankers and investors who invest in health care companies.

Over the past few weeks, investment bankers have been candid on investor calls and during health care conferences about the opportunity to raise drug prices. In some cases, bankers received sharp rebukes from health care executives; in others, executives joked about using the attention on Covid-19 to dodge public pressure on the opioid crisis.

Gilead Sciences, the company producing remdesivir, the most promising drug to treat Covid-19 symptoms, is one such firm facing investor pressure.

Remdesivir is an antiviral that began development as a treatment for dengue, West Nile virus, and Zika, as well as MERS and SARS. The World Health Organization has said there is “only one drug right now that we think may have real efficacy in treating coronavirus symptoms” — namely, remdesivir.

The drug, though developed in partnership with the University of Alabama through a grant from the federal government’s National Institutes of Health, is patented by Gilead Sciences, a major pharmaceutical company based in California. The firm has faced sharp criticism in the past for its pricing practices. It previously charged $84,000 for a yearlong supply of its hepatitis C treatment, which was also developed with government research support. Remdesivir is estimated to produce a one-time revenue of $2.5 billion.

During an investor conference earlier this month, Phil Nadeau, managing director at investment bank Cowen & Co., quizzed Gilead Science executives over whether the firm had planned for a “commercial strategy for remdesivir” or could “create a business out of remdesivir.”

Johanna Mercier, executive vice president of Gilead, noted that the company is currently donating products and “manufacturing at risk and increasing our capacity” to do its best to find a solution to the pandemic. The company at the moment is focused, she said, primarily on “patient access” and “government access” for remdesivir.

“Commercial opportunity,” Mercier added, “might come if this becomes a seasonal disease or stockpiling comes into play, but that’s much later down the line.”

Steven Valiquette, a managing director at Barclays Investment Bank, last week peppered executives from Cardinal Health, a health care distributor of N95 masks, ventilators and pharmaceuticals, on whether the company would raise prices on a range of supplies.

Valiquette asked repeatedly about potential price increases on a variety of products. Could the company, he asked, “offset some of the risk of volume shortages” on the “pricing side”?

Michael Kaufmann, the chief executive of Cardinal Health, said that “so far, we’ve not seen any material price increases that I would say are related to the coronavirus yet.” Cardinal Health, Kaufman said, would weigh a variety of factors when making these decisions, and added that the company is “always going to fight aggressively to make sure that we’re getting after the lowest cost.”

“Are you able to raise the price on some of this to offset what could be some volume shortages such that it all kind of nets out to be fairly consistent as far as your overall profit matrix?” asked Valiquette.

Kaufman responded that price decisions would depend on contracts with providers, though the firm has greater flexibility over some drug sales. “As you have changes on the cost side, you’re able to make some adjustments,” he noted.

The discussion, over conference call, occurred during the Barclays Global Healthcare Conference on March 10. At one point, Valiquette joked that “one positive” about the coronavirus would be a “silver lining” that Cardinal Health may receive “less questions” about opioid-related lawsuits.

Cardinal Health is one of several firms accused of ignoring warnings and flooding pharmacies known as so-called pill mills with shipments of millions of highly addictive painkillers. Kaufmann noted that negotiations for a settlement are ongoing.

Owens & Minor, a health care logistics company that sources and manufactures surgical gowns, N95 masks, and other medical equipment, presented at the Barclays Global Healthcare Conference the following day.

Valiquette, citing the Covid-19 crisis, asked the company whether it could “increase prices on some of the products where there’s greater demand.” Valiquette then chuckled, adding that doing so “is probably not politically all that great in the sort of dynamic,” but said he was “curious to get some thoughts” on whether the firm would consider hiking prices.

The inquiry was sharply rebuked by Owens & Minor chief executive Edward Pesicka. “I think in a crisis like this, our mission is really around serving the customer. And from an integrity standpoint, we have pricing agreements,” Pesicka said. “So we are not going to go out and leverage this and try to ‘jam up’ customers and raise prices to have short-term benefit.”

AmerisourceBergen, another health care distributor that supplies similar products to Cardinal Health, which is also a defendant in the multistate opioid litigation, faced similar questions from Valiquette at the Barclays event.

Steve Collis, president and chief executive of AmerisourceBergen, noted that his company has been actively involved in efforts to push back against political demands to limit the price of pharmaceutical products.

Collis said that he was recently at a dinner with other pharmaceutical firms involved with developing “vaccines for the coronavirus” and was reminded that the U.S. firms, operating under limited drug price intervention, were among the industry leaders — a claim that has been disputed by experts who note that lack of regulation in the drug industry has led to few investments in viral treatments, which are seen as less lucrative. Leading firms developing a vaccine for Covid-19 are based in Germany, China, and Japan, countries with high levels of government influence in the pharmaceutical industry.

AmerisourceBergen, Collis continued, has been “very active with key stakeholders in D.C., and our priority is to educate policymakers about the impact of policy changes,” with a focus on “rational and responsible discussion about drug pricing.”

Later in the conversation, Valiquette asked AmerisourceBergen about the opioid litigation. The lawsuits could cost as much as $150 billion among the various pharmaceutical and drug distributor defendants. Purdue Pharma, one of the firms targeted with the opioid litigation, has already pursued bankruptcy protection in response to the lawsuit threat.

“We can’t say too much,” Collis responded. But the executive hinted that his company is using its crucial role in responding to the pandemic crisis as leverage in the settlement negotiations. “I would say that this crisis, the coronavirus crisis, actually highlights a lot of what we’ve been saying, how important it is for us to be very strong financial companies and to have strong cash flow ability to invest in our business and to continue to grow our business and our relationship with our customers,” Collis said.

The hope that the coronavirus will benefit firms involved in the opioid crisis has already materialized in some ways. New York Attorney General Letitia James announced last week that her lawsuit against opioid firms and distributors, including Cardinal Health and AmerisourceBergen, set to begin on March 20, would be delayed over coronavirus concerns.

MARKET PRESSURE has encouraged large health care firms to spend billions of dollars on stock buybacks and lobbying, rather than research and development. Barclays declined to comment, and Cowen & Co. did not respond to a request for comment.

The fallout over the coronavirus could pose potential risks for for-profit health care operators. In Spain, the government seized control of private health care providers, including privately run hospitals, to manage the demand for treatment for patients with Covid-19.

But pharmaceutical interests in the U.S. have a large degree of political power. Health and Human Services Secretary Alex Azar previously served as president of the U.S. division of drug giant Eli Lilly and on the board of the Biotechnology Innovation Organization, a drug lobby group.

During a congressional hearing last month, Azar rejected the notion that any vaccine or treatment for Covid-19 should be set at an affordable price. “We would want to ensure that we work to make it affordable, but we can’t control that price because we need the private sector to invest,” said Azar. “The priority is to get vaccines and therapeutics. Price controls won’t get us there.”

The initial $8.3 billion coronavirus spending bill passed in early March to provide financial support for research into vaccines and other drug treatments contained a provision that prevents the government from delaying the introduction of any new pharmaceutical to address the crisis over affordability concerns. The legislative text was shaped, according to reports, by industry lobbyists.

As The Intercept previously reported, Joe Grogan, a key White House domestic policy adviser now serving on Donald Trump’s Coronavirus Task Force, previously served as a lobbyist for Gilead Sciences.

“Notwithstanding the pressure they may feel from the markets, corporate CEOs have large amounts of discretion and in this case, they should be very mindful of price gouging, they’re going to be facing a lot more than reputational hits,” said Robert Weissman, president of public interest watchdog Public Citizen, in an interview with The Intercept.

“There will be a backlash that will both prevent their profiteering, but also may push to more structural limitations on their monopolies and authority moving forward,” Weissman said.

Weissman’s group supports an effort led by Rep. Andy Levin, D-Mich., who has called on the government to invoke the Defense Production Act to scale up domestic manufacturing of health care supplies.

There are other steps the government can take, Weissman added, to prevent price gouging.

“The Gilead product is patent-protected and monopoly-protected, but the government has a big claim over that product because of the investment it’s made,” said Weissman.

“The government has special authority to have generic competition for products it helped fund and prevent nonexclusive licensing for products it helped fund,” Weissman continued. “Even for products that have no connection to government funding, the government has the ability to force licensing for generic competition for its own acquisition and purchases.”

Drug companies often eschew vaccine development because of the limited profit potential for a one-time treatment. Testing kit companies and other medical supply firms have few market incentives for domestic production, especially scaling up an entire factory for short-term use. Instead, Levin and Weissman have argued, the government should take direct control of producing the necessary medical supplies and generic drug production.

Last Friday, Levin circulated a letter signed by other House Democrats that called for the government to take charge in producing ventilators, N95 respirators, and other critical supplies facing shortages.

The once inconceivable policy was endorsed on Wednesday when Trump unveiled a plan to invoke the Defense Production Act to compel private firms to produce needed supplies during the crisis. The law, notably, allows the president to set a price ceiling for critical goods used in an emergency.

 

 

 

 

To solve the economic crisis, we will have to solve the health-care crisis

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In Washington, the focus has now turned to the economic response to the coronavirus pandemic, with experts and politicians proposing their preferred policy tools — ranging from tax cuts to corporate bailouts to direct payments of cash. Each is worth debating, but the focus is misplaced. This is not an economic crisis; it is a health-care crisis.

The distinction may sound academic. But understanding it is actually vital to designing the policies that should follow.

In an economic crisis, you could imagine a situation in which people lose their jobs and are unable to spend money. That’s called a demand shock, which is what happened during the global financial crisis of 2008. Or producers could raise prices (for various reasons), making it harder to buy their goods. That’s a supply shock, and it describes the oil crises of 1973 and 1979. But what is happening now cannot be addressed primarily by economic responses, because we are witnessing the suspension of economics itself.

Today, even if you have money, increasingly you cannot go into a shop, restaurant, theater, sports arena or mall because those places are closed. If you own a factory that hasn’t already closed for health reasons, you may still have to shut it down because you can’t get key components from suppliers or you can’t find enough stores open to sell your goods.

In these conditions, cash to consumers cannot jump-start consumption. Relief to producers will not jump-start production. This problem is on a level different and far greater than the recession of 2008 or the aftermath of 9/11. If it were to go on for months, it could look worse than the Great Depression.

This is not an argument against any of the economic measures being proposed. People need to be able to eat, buy medicine and pay their bills. New York Times columnist Andrew Ross Sorkin has canvassed experts and concluded that the best approach would be a zero-interest “bridge loan” to all businesses and self-employed people as long as they keep most of their workers on staff. It is probably the right course of action, massively expensive but cheaper than a full-blown Great Depression.

But even that might not work if we do not recognize that first and foremost the United States faces a health crisis. And that crisis is not being solved. China is now reporting no new domestic infections. South Korea, Taiwan and Singapore have also made progress in “flattening the curve” — the phrase of the year — because they have prioritized dealing with the health-care crisis over enacting a grand economic stimulus.

The United States is still dangerously behind the curve. A headline in Thursday’s Wall Street Journal is, “Coronavirus Testing Chaos Across America.” The article details how the country still has “a chaotic patchwork of testing sites,” with testing proceeding “far slower than experts say is necessary, in part due to a slow federal response.” The U.S. testing rate remains shockingly low, well behind the rates of most other rich countries and far behind those of the Asian countries that are handling this crisis best. Across the United States, hospitals are warning of a dire shortage of beds, medical equipment and supplies. And the worst is yet to come. With infections doubling every two to three days, the U.S. health-care system will face what New York Gov. Andrew Cuomo correctly described as a “tsunami.”

The Trump administration is still acting slowly and fitfully. Experts predicted weeks ago that cities would need thousands more hospital beds, and yet the Navy is still performing maintenance on two hospital ships and figuring out staffing. The president says he will invoke “defense production” powers only if necessary. What is he waiting for? He should direct firms to start production of all key medical equipment in short supply. The armed forces should be deployed immediately to set up field testing and hospital sites. Hotels and convention centers should be turned into hospitals. The federal government should announce a Manhattan Project-style public-private partnership to find and produce a vaccine. After decades of attacks on government, federal agencies are understaffed, underfunded and ill-equipped to handle a crisis of this magnitude. They need help, and fast.

And here’s another idea: President Trump could forge an international effort to unite the world against this common threat. If the United States, China and the European Union worked together, prospects for success — on a vaccine, for example — would be greater. China in particular produces most of the supplies and medical ingredients the world needs. Trump should remove all of his self-defeating tariffs so that American consumers don’t have to pay more for these goods and China can ramp up production. This is a war, and in a war you try to find allies rather than create enemies.

 

 

Coronavirus will radically alter the U.S.

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Here’s what may lie ahead based on math models, hospital projections and past pandemics.

When Jason Christie, chief of pulmonary medicine at Penn Medicine, got projections on how many coronavirus patients might soon be flocking to his Philadelphia hospital, he said he felt physically ill.

“My front-line providers — we were speaking about it in the situation report that night, and their voices cracked,” Christie said on Wednesday. They saw how quickly the surge would overwhelm the system, forcing doctors to make impossible choices — which patients would get ventilators and beds, and which would die.

“They were terrified. And that was the best-case scenario.”

Experts around the country have been churning out model after model — marshaling every tool from math, medicine, science and history — to try to predict the coming chaos unleashed by the new coronavirus and to make preparations.

At the heart of their algorithms is a scary but empowering truth: What happens next depends largely on us — our government, politicians, health institutions and, in particular, 327 million inhabitants of this country — all making tiny decisions on an daily basis with outsize consequences for our collective future.

In the worst-case scenario, America is on a trajectory toward 1.1 million deaths. That model envisions the sick pouring into hospitals, overwhelming even makeshift beds in parking lot tents. Doctors would have to make agonizing decisions about who gets scarce resources. Shortages of front-line clinicians would worsen as they get infected, some dying alongside their patients. Trust in government, already tenuous, would erode further.

That grim scenario is by no means a foregone conclusion — as demonstrated by countries like South Korea which has reduced its new cases a day from hundreds to dozens with aggressive steps to bolster their health system.

If Americans embrace drastic restrictions and school closures, for instance, we could see a death toll closer to thousands and a national sigh of relief as we prepare for a grueling but surmountable road ahead.

An alarming new model

Doing that will require Americans to “flatten the curve” — slowing the spread of the contagion so it doesn’t overwhelm a health-care system with finite resources. That phrase has become ubiquitous in our national conversation. But what experts have not always made clear is that by applying all that downward pressure on the curve — by canceling public gatherings, closing schools, quarantining the sick and enforcing social distancing — you elongate the curve, stretching it out over a longer period of time.

Success means a longer — though less catastrophic — fight against the coronavirus. And it is unclear whether Americans — who built this country on ideals of independence and individual rights — would be willing to endure such harsh restrictions on their lives for months, let alone for a year or more.

This month began with U.S. officials recommending actions such as hand-washing and social distancing. By Sunday, the Centers for Disease Control and Prevention was warning against gatherings of 50-plus people. By Monday, President Trump had made an abrupt turn from encouraging Americans to go on with their lives, to urging them to work from home, not meet in groups of more than 10, and calling on local officials to close schools, bars and restaurants. (Getting the public to comply has been alarmingly difficult. Young revelers from Bourbon Street to Miami have ignored those pleas, as have some elderly, who are at highest risk.)

Trump’s sudden shift was driven by an alarming new scientific model, developed by British epidemiologists and shared with the White House. The scientists bluntly stated the coronavirus is the most serious respiratory virus threat since the Spanish Flu of 1918. If no action to limit the viral spread were taken, as many as 2.2 million people in the United States could die over the course of the pandemic, according to epidemiologist Neil Ferguson and others at the Imperial College Covid-19 Response Team.

Adopting some mitigation strategies to slow the pandemic — such as isolating those suspected of being infected and social distancing of the elderly — only cuts the death toll in half to 1.1 million, although it would reduce demand for health services by two-thirds.

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Only by enacting an entire series of drastic, severe restrictions could America shrink its death toll further, the study found. That strategy would require, at minimum, the nationwide practice of social distancing, home isolation, and school and university closures. Such restrictions would have to be maintained, at least intermittently, until a working vaccine is developed, which could take 12 to 18 months at best.

The report’s conclusion: This is “the only viable strategy.”

What hospital planning tells us

Here is another thing that hasn’t been spelled out in our national conversation about flattening the curve: There will probably be more than one curve.

If we’re lucky, the coming months will probably look more like string of hilly bumps, say epidemiologists. If authorities ease some measures in coming months or if we start letting them slip ourselves, that hill could easily turn right back into the exponential curve that has cratered Italy’s health system and that U.S. officials are desperately trying to avoid replicating.

Climbing this first bump is in many ways the most challenging because it involves persuading people to change their individual behaviors for an abstract larger good — and because no one knows how far we actually are from the peak.

On Tuesday morning, New York Gov. Andrew M. Cuomo (D) said infections in his state are expected to peak in 45 days — at the start of May. The state has roughly 53,000 hospital beds, including 3,000 intensive-care beds — way short of the projected need for as many as twice that number of beds and as many as 11 times the number of ICU beds.

A day earlier, Northwell Health — whose 23 hospitals and 800 outpatient centers make up New York’s largest health system — canceled all elective surgeries in its hospitals to free up staff and space. It has 5,500 beds.

“We’re looking at Italy, which is currently 10 days ahead of us, and what they’ve had to do,” said Maria Carney, Northwell’s chief of geriatrics. Carney was health commissioner for New York’s Nassau County during the 2009 H1N1 outbreak and has worked furiously on Northwell’s plans to prepare for the coming tsunami.

One reason she and others are alarmed: In China, the fatality rate in Wuhan, the raging epicenter, was 5.8 percent. But in all other areas of the country it was 0.7 percent — a signal that most deaths were driven by an overwhelmed health system.

And U.S. hospitals are pinched as it is, with some already running at 95 percent capacity pre-coronavirus, Carney noted. As cases surge, Northwell plans to place multiple beds in single rooms. Its ambulances will also shuttle patients to less crowded satellite sites. Those suffering from ordinary emergencies — strokes, heart attacks, car accidents — may find themselves routed to other facilities away from ERs to avoid transmission.

But it’s unclear if it will be anywhere near enough.

Staffing shortages are already developing: As of Tuesday, 18 Northwell employees had already tested positive for the coronavirus. More than 200 were self-quarantined as a result of potential exposures, foreshadowing what is likely to come.

If the numbers next month get truly crazy, cities may look to convert stadiums into isolation wards, as in Wuhan. Cuomo has talked of turning the six-block-long Javits Convention Center on New York City’s west side into a medical surge facility. Others might take Italy’s approach and split hospitals into those treating coronavirus and those treating all other medical problems, to reduce transmission.

In San Francisco, we may see coronavirus patients put into RVs. In Takoma Park, Md., the old Washington Adventist Hospital site, which shuttered in 2019, could suddenly find its doors reopened.

‘Pandemics aren’t just physical’

As America enters this utterly unfamiliar territory, some experts have turned to history for glimpses of what to expect in the months ahead.

Initially leery of alarming the public, they have increasingly compared this pandemic to the 1918 Spanish flu, the deadliest in modern history. It infected roughly a third of the world’s population and killed at least 50 million people, including at least 675,000 in the United States.

Like the hilly bumps experts foresee in coming months, the 1918 pandemic hit America in three waves — a mild one that spring, the deadliest wave in fall and a final one that winter.

With each wave came a cycle of denial, devastation, community response finally kicking into overdrive — always followed by finger-pointing and blame among leaders and the public.

“Every outbreak is different,” said medical anthropologist Monica Schoch-Spana, who spent months digging through archives to study how Spanish flu played out in Baltimore.

Like coronavirus is likely to do, the 1918 flu overwhelmed hospitals. Unable to get help, desperate families waited outside to beg and try to bribe doctors for treatment. In a three-week period, 2,000 died in Baltimore alone. Mortuaries ran out of caskets. When the bodies finally reached cemeteries, the gravediggers were so ill, no one could bury the dead.

Economic pressure on business owners and workers caused public resistance to adopt — and stick with restrictions. The crisis brought out the best in Baltimoreans — with sewing circles churning out gauze masks and hospital bedding, and neighbors donating food and services.

But it also brought out the worst — xenophobic conspiracy theories that nurses of “German extraction” were deliberately infecting people. African American patients were kept out of most hospitals under Jim Crow-era segregation.

“Pandemics aren’t just physical,” said Schoch-Spana. “They bring with them an almost shadow pandemic of psychological and societal injuries as well.”

The power of the individual

Stanford virologist Karla Kirkegaard said she has tried to stave off dread from the projected U.S. death toll with a case study she teaches in her classes:

Amid a cholera outbreak in mid-19th century London, as panicked residents fled one hard-hit neighborhood, a doctor named John Snow calmly entered the breach. He deduced that the source of hundreds of deaths was a single contaminated water pump and persuaded authorities to remove the pump’s handle — a strategy that ended the outbreak.

Controlling the covid-19 pandemic will take much more than a single water pump, Kirkegaard acknowledged as she sheltered in place at her Bay Area home.

But the story, she said, reminds her how powerful the simple act of one individual can be.

 

4 ETHICAL DILEMMAS FOR HEALTHCARE ORGANIZATIONS DURING THE COVID-19 PANDEMIC

Posted on by • Posted in Health Policy, Health System, Healthcare Ethics, Hospital, Hospital Industry, Infection Control, Infectious Virus, Intensive Care (ICU), Leadership, Medical Utility, Pandemic, Physician, Public Health, Public Safety, Quarantine, Rationing Care, Triage, Vaccination, Vaccine, Ventilators • Leave a comment

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There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.

KEY TAKEAWAYS

Rationing of care for novel coronavirus patients has been reported in China and Italy.

Medical utility based on scientific patient profiles should guide decisions to ration critical care resources such as ventilators, medical ethicist James Tabery says.

In a pandemic, public health considerations should drive decisions on prioritizing who is tested for disease, he says.

The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.

In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.

The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. “Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn’t enough of these resources than what we anticipate needing,” says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.

He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.

1. TREATMENT

In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. “The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can.”

The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.

“But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility,” Tabery says.

Medical utility is based on scientific assessments, he says. “You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient’s condition quickly.”

Rationing of critical care resources would be jarring for U.S. clinical staff.

Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.

However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.

“When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn’t look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck,” he says.

2. TESTING

There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.

While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.

“The primary purpose of the test is pure public health epidemiology. It’s about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn’t so much about who is at greatest risk. It’s about who is more likely to interact with lots of people, or who is more likely to have interacted with more people.”

A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.

“For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street.”

3. HEALTHCARE WORKERS

The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. “On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don’t want to get sick, which can incline them not to work,” he says.

“The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work,” he says.

However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. “If hospitals don’t have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem.”

4. VACCINE

When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.

“When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups,” he says.

 

 

 

 

Doctors Fear Bringing Coronavirus Home: ‘I Am Sort of a Pariah in My Family’

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One doctor dreamed he was surrounded by coughing patients. “Most physicians have never seen this level of angst and anxiety in their careers,” a veteran emergency room doctor said.

SEATTLE — After her shifts in the emergency room, one doctor in Utah strips naked on her porch and runs straight to a shower, trying not to contaminate her home. In Oregon, an emergency physician talks of how he was recently bent over a drunk teenager, stapling a head wound, when he realized with a sudden chill that the patient had a fever and a cough. A doctor in Washington State woke up one night not long ago with nightmares of being surrounded by coughing patients.

“Most physicians have never seen this level of angst and anxiety in their careers,” said Dr. Stephen Anderson, a 35-year veteran of emergency rooms in a suburb south of Seattle. “I am sort of a pariah in my family. I am dipping myself into the swamp every day.”

As the coronavirus expands around the country, doctors and nurses working in emergency rooms are suddenly wary of everyone walking in the door with a cough, forced to make quick, harrowing decisions to help save not only their patients’ lives, but their own.

The stress only grew on Sunday, when the American College of Emergency Physicians revealed that two emergency medicine doctors, in New Jersey and Washington State, were hospitalized in critical condition as a result of the coronavirus. Though the virus is spreading in the community and there was no way of ascertaining whether they were exposed at work or somewhere else, the two cases prompted urgent new questions among doctors about how many precautions are enough.

“Now that we see front-line providers that are on ventilators, it is really driving it home,” Dr. Anderson said.

Doctors, nurses and other staff members in a variety of hospital departments face new uncertainty. In intensive care units, for example, health care providers must have extended exposure to people who have contracted the virus. But they know in advance of the risk they face.

In emergency departments, the danger comes from the unknown.

Patients arrive with symptoms but no diagnosis, and staff members must sometimes tend to urgent needs, such as gaping wounds, before they have time to screen a patient for Covid-19, the disease caused by the virus. At times, the protocols they must follow are changing every few hours.

“Many of us have trained for disasters, like Ebola and hurricanes,” said Dr. Adam Brown, the president of emergency medicine for Envision Healthcare, the largest provider of contract physicians to emergency rooms. “This is different because of the scale and scope of the disease.”

Add to that the shortage of protective gear and delays in testing, and health care workers fear they are flying blind.

Though the numbers are still low, Envision, which employs 11,000 emergency clinicians across the United States, has five times as many doctors under quarantine as it did a week ago, Dr. Brown said.

Several providers spoke on the condition of anonymity because their employers have told them not to talk to the news media.

The personal strain is cascading as the virus reaches new parts of the country. “Everybody feels the stress, but everybody is pulling together,” said Dr. K. Kay Moody, an emergency room doctor in Olympia, Wash., who runs a Facebook group with 22,000 emergency physicians. “That is what is keeping us OK.”

A few doctors said they were talking about bunking up in Airbnbs to create “dirty doc” living quarters to avoid endangering their children when they go home. Some are showing their partners where to find their passwords and insurance, should they end up in intensive care. Dr. Moody said she knew of at least one doctor whose former spouse was threatening to take their children away if the doctor went to work.

Many emergency physicians work as contractors, not hospital staff, so they will not necessarily be paid if they are quarantined. “As it stands, that is one of the most anxiety-provoking things,” Dr. Moody said, “on top of fear for your life.”

Nurses face similar challenges, though with less pay and support. An emergency nurse in Milwaukee said she bought her own goggles after hearing that protective gear was running low. A nurse at a rural hospital near Lake Tahoe in California said that the hospital was providing physicians with shower facilities as well as clean scrubs to wear, but that nurses had to wash their work clothes at home. She said that the physicians she worked with lobbied the hospital to provide clean scrubs for the nurses, but that the hospital concluded it would cost too much.

One doctor, who spoke on condition that the identity of the veterans hospital where she worked was not revealed, said the protocols have not kept up with the changing reality on the ground. When determining if a patient should get a separate room, she said, the emergency department still asks patients if they have been to high-risk countries, like China and Italy, even though community transmission of the virus has been well established.

Doctors have begun building plans for how they will ration supplies when there are more patients than their hospitals can handle. Emergency room doctors have experience sitting families down to advise discontinuing care because it would be futile. But in the United States, they are not used to making such calls based on resources alone.

Some said they were looking to Italy, where doctors on the front line have sometimes had to ration care in favor of younger patients, or those without other complicating conditions, who are more likely to benefit from it.

“If we get it all at once, we don’t have the resources, we don’t have the ventilators,” said Dr. William Jaquis, chair of the American College of Emergency Physicians.

Last week, Italian media reported that Bergamo, a city northeast of Milan, saw roughly 50 doctors test positive for the virus. In the region of Puglia in the south, local media reported that 76 employees had been quarantined after being exposed to patients who contracted Covid-19.

After the coronavirus broke out at a nursing facility near Seattle, Dr. Anderson sat with the leaders of his hospital, MultiCare Auburn Medical Center, to talk about how urgently they should prepare. Their hospital is ringed by nursing homes and other care facilities, and he rattled off those most at risk for fatal cases of the virus: males over 60, and those with cardiac and pulmonary problems. “I literally stopped what I was saying and realized that that was me,” he said.

He said his hospital was down to a two-day supply of surgical masks — he wears one per shift. “Those are supposed to be disposable,” he said. Now he must carefully remove and clean the mask each time he takes it off and on. “That may sound just like a nuisance, but when you’re potentially touching something that has the virus that could kill you on it, and you’re doing it 25 times a shift, it’s kind of nerve-racking,” he said.

His wife has moved to their mountain cabin, and they have given up on their retirement cruise in Europe. “I haven’t slept for longer than three hours in the past two weeks,” he said.

In the early hours of Monday morning, he could not sleep. More than 200 emails had come into his inbox since he went to bed, including news that three other health care providers had been admitted to a hospital overnight, he said.

But he plans to be at his next shift nonetheless.

“I have been doing this for 35 years,” he said, “and I’m not going to stop now.”

 

 

 

 

I’m a Doctor in Italy. We Have Never Seen Anything Like This.

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My country’s health care system may soon collapse.

MILAN — None of us have ever experienced a tragedy like it.

We know how to respond to road accidents, train derailments, even earthquakes. But a virus that has killed so many, which gets worse with each passing day and for which a cure — or even containment — seems distant? No.

We always think of calamity as something that will happen far from us, to others far away, in another part of the world. It’s a kind of superstition. But not this time. This time it happened here, to us — to our loved ones, our neighbors, our colleagues.

I’m an anesthesiologist at the Policlinico San Donato here in Milan, which is part of the Lombardy region, the heart of the Italian coronavirus outbreak. On Feb. 21, the day on which the first case was recorded, our hospital, which specializes in cardiac surgery, offered to help with the care of patients with Covid-19. Along with other hospitals, we created a task force of intensive care doctors to be sent to hospitals in the “red zone.”

All planned surgeries were postponed. Intensive care beds were given over to the treatment of coronavirus patients. Within 24 hours, the hospital created new intensive care places by converting operating theaters and anesthetic rooms. And 40 more beds were dedicated to patients suspected or proven to have the virus, though not in a serious condition.

But the increases in cases are astounding. As of Tuesday, nationwide, there were 31,506 cases, of which 2,941 recovered and 2,503 died. Lombardy, the region most affected, has 16,220 cases, with 1,640 dead, 879 in intensive care — 56 more than the day before — and 2,485 clinically cured. With these numbers, the country’s health care system may soon collapse.

The patients who arrive remain for many days, straining medical resources. Already across northern Italy — in Lombardy, Veneto, Emilia-Romagna and Marche — health care systems are under enormous stress. Medical workers are exhausted. As the virus spreads, other regions will soon find themselves in the same situation.

Fortunately, Lombardy and the national government adopted aggressive containment measures 10 days ago. By the end of this week — after 15 days, the incubation period of the infection — we will see whether such measures have been effective. Only then might we see a slowing down in the spread of the virus.

It cannot come too soon. There has been speculation that doctors may be forced to decide whom to treat, leaving some without immediate care. That’s not my experience: All patients at my hospital have received the treatment they require. But that may not last. If the number of patients infected does not start to drop, our resources won’t stretch to cover them. At that point, triaging patients — to give priority to those with more chances of survival — may become standard practice.

My colleagues, at the Policlinico and throughout the country, are showing a great spirit of sacrifice. We know how much we are needed right now; that gives us strength to withstand fatigue and stress. How long such resistance will last, I cannot say. Some colleagues have tested positive for the coronavirus, and a few have needed intensive care. For us all, the dangers are great.

As an anesthesiologist devoted to surgical emergencies, I haven’t had many direct dealings with coronavirus patients. But there was one. An elderly man in a fragile condition, he was set to have tumor removed. The surgery proceeded as normal: I put him to sleep, and he awoke four hours later, without pain.

That was in mid-February. A week later, the telltale symptoms began to show: a high fever, a cough. Before long, pneumonia. Now he’s in intensive care, intubated and in a critical condition. He is one of many who have become a number without a name, one of those that represent the worsening of the situation.

I hope the beginning of the end of this outbreak will be soon. But we will know that it’s coming only if and when the infections begin to decline.

The population’s calm response to the restrictive rules imposed by the government, the experience gained in the management of critically ill patients and the rumors of new treatments for the infection are grounds for hope. Perhaps the containment measures will work, and the news at the end of the week will be good.

But for now, we are in the thick of tragedy.