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 Welcome to this Week in Health It, where we amplify great thinking to Propel Healthcare Forward. My name is Bill Russell Healthcare, CIO, coach and creator of this week in Health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. Have you missed our live show?

It is only available on our YouTube channel. What a fantastic conversation we had with, uh, direct for David Mu Shade. Around what's next in health. It, uh, you can view it on our website with our new menu item appropriately named live. Or just jump over to the YouTube channel. And while you're at it, you might as well subscribe to our YouTube channel and click on Get Notifications to get access to a bunch of content only available on our YouTube channel.

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Special thanks to Sirius for supporting the show's efforts during the crisis. Now onto today's show. Alright, today we're joined by Dr. David Sma, friend and advisor to the show. Good morning, David, and welcome back to the show. Bill, thank you for having me. Well, you know, I was trying to think who could I have this interest?

I have this idea for a show I.

Something a little different, a little off the track of health it. We're gonna do a little point counterpoint and try to capture the, the current sentiment of the discussion in the us. Uh, what I'm picturing is a conversation between a patient who just lost his job and wants to go back to work represented by me and, uh, his physician represented by you.

And, um. And so we're gonna do a little point counterpoint. This is gonna be an imperfect conversation from two imperfect people as we explore really the handling of the pandemic. And I would just ask people to give us a little grace here. Don't hate the messengers from either side. Uh, really consider the show as a time capsule for the conversations that are going on.

All over the country. I actually went out and hit social media, collected a bunch of the stuff straight from social media. I called some people that I know were, uh, not happy with, uh, the shelter in place and whatnot. And I said, if you were sitting across from a doctor, what questions would you ask? So I actually.

A fair amount of research to get questions word for word from, uh, the people who were asking them to try to make this as authentic as possible. So, uh, let's, let's start with the, you know, let's start with the, the most obvious question, which is, uh, what do we really know about Covid 19 at this point? Uh, things around transmission rate, transmission lethality, and those kinds of things.

Yeah, I, I think one of the things we definitely know is how little we know. Um, and if we have the humility to recognize that, then we can join together to move forward instead of polarizing. Uh, what we do know is that it is something not seen before, so none of us had immunity. That makes it a unique setting.

Um, influenza, each year we have some. Um, not even counting vaccines. We have some immunity within the population that helps to mitigate it. Um, we don't have that. The other thing that we know is that it is highly, highly transmissible, uh, through droplets. So close contact, respiration, um, coughing, uh, all help to transmit it.

We also know it can transfer from a fomite, um, not as effectively as by droplet transmission, but still, um, fomites, inanimate objects. Um, it can live on those for periods of times, and we've seen that the, uh, studies show it hangs out longer on some of the hard surfaces than we thought it, and we know about it.

A predilection for susceptible populations, and we've all heard, um, who the susceptible populations are. One of the interesting add-ons to that is, um, people who are exercising aggressively who get exposed during that time actually have a propensity towards the pneumonia because their inspiration, their volume of air movement.

Bypasses the normal upper respiratory and um, upper bronchial immuno, um, response and lets the virus get right to the alveoli, air sacs in the lungs and cause disease. So we're seeing that in some young, highly trained athletes and that's kind of an interesting thing that's making us more aware that.

I would've to have thought that, oh, it's only our very aged and multi illness patients. Um, it is a large segment of the population and now we're looking at some of the Kawasaki like syndrome in children and some of the other manifestations in children, and we're realizing, you know, again, none of us have immunity.

All of us are gonna have some form of a response, and we're getting a.

Now we have to fine tune understanding even more which populations are at risk. Alright, so, um, here's, here's the interesting thing. So I, you know, I have questions here that are, you know, easier, harder. I'm just gonna go through 'em. And actually since you, since you brought up, uh, exercise and those kinds of things, um.

You know, I, I approach this from two perspectives. One is, you know, the question is, you know, when, when are we gonna be able to go to a crowded stadium, a sports event, or a concert in the future? Uh, that's one question. But the second would be, is it, um, you know, is it safe for people to participate in a baseball game?

If what you just described is, is one of the potential outcomes? Um, as far as when do we get to go back to Crowded Stadium, um, either a truly effective vaccine with a high penetration of immunization in the population or second, um, the population at large has had enough disease, uh, penetration that we have over 60% of the population having had the virus and then having immunity if indeed.

They're still trying to figure out, you know, do we have long-term immunity after recovery from the virus? So when either of those conditions is met, then we can crowd the stadiums. In terms of, is there a risk for people in sports baseball a lot less than others? 'cause the proximity and contacts are generally, um, reduced.

Only times are, um, at tagging and, uh, those don't happen that often. But it's still a possibility. Um, I would think more soccer or football too. The rest of the world. Um, soccer, you're in close proximity frequently and aspiring at a high rate. I would think that would be a very dangerous basketball.

Likewise, very dangerous. And you know, here the NBA wants to come back. Is that going to be safe? I don't know. I don't think so. Yeah. So if we, if we do well, I don't wanna get stuck on that question because there's, there's so many questions here. I was gonna say, if we do testing and everybody in the game is, um, you know, is, is covid free or, or, you know, not, uh, you know, not infectious at that point, uh, is that game safe?

Should we consider it safe? It is a lot safer than if you didn't do testing and, and allowed just everyone there and maybe had some folks who were asymptomatically, um, uh, infected. However, my concern is that the tests that are so far available still don't meet what we used to consider to be the threshold for sensitivity and specificity.

So the false negative rate and the false positive rates are really quite high. False positives, fine. You're going to exclude 'em from the game and that's a problem for the athlete, but it's saves the others. False negatives is a real problem, and when you have 8% false negatives being a good test.

Currently that's still too high to really provide mitigation. All right, so, um, yeah, this, again, people don't shoot the messenger. I'm just pulling this stuff off of social media and, and, and different things that I've read. So, 68,000 deaths as of this morning. Uh. Them are in and around New York City. And the question really is, uh, if you take those numbers out, if you take the New York City numbers out of the total, don't we just have a bad flu season?

Is this a big city mass transportation, high-rise, elevator centric problem, living in close proximity problem? Uh, because when you look at some of the other more spread out cities like

orange. And, and those are two places. Keep in mind that they have an awful lot of travel between China and the West coast. So, um, do we have just a, a close proximity living problem and a New York and other really close proximity, uh, living issue? We don't, um, we have a worsening in close proximity, but we have the problem of people who work in roles.

Where they cannot distance themselves, protect themselves. So it can be in a small area, so it is a crowding or a proximity issue, but it can happen in a lot of places that you would not anticipate. North Dakota is, you know, one of the, um, ones the news agencies are going to because the meat packing plan up there and the issues they had.

Um, yes, we would see a lot less numbers if. Um, New York was taken out of the equation, but you've gotta believe that New York is Chicago, Detroit. Um, yeah, LA is spread out. San Francisco's not as much, um, spread out. And so you, you still have some cities at significant risk. And then you've got areas where you could get pocket of infection as.

And in a smaller population have pretty high percentage of, um, case, um, incidents. Yeah. So, so I live in a community. This is, you know, um, I talked to somebody yesterday and this is essentially the question they gave, gave me. And we live in the same community. I live in a community of about a thousand people in Florida.

It's a community with a fair amount of retirees.

You know, we have proximity to large cities here in Florida. It's not like we're that far away from Orlando, Tampa, and Miami. Um, and the fact is we never closed the golf course. The tennis courts are still open. Pickle ball's still open. FedEx and Amazon, you know, might as well have a race track out here.

Their, their trucks are going through the community almost on an hourly basis, as well as contractors are still going in and outta houses and doing work on a regular basis.

I had heard of any cases until late in the stay, and then one of the, uh, uh, church members at the Presbyterian church was reported to have, um, succumbed and, you know, where did that case come from? Was it imported to this isolated area or was it, um, somebody, is there a population with asymptomatic disease in the.

And so, yeah, it can pop up anywhere. The likelihood that you're in a community that has not seen at least a case, um, is slim enough. Yeah. And, and so you would think we'd see something, right? We, I mean, this is an older community. Somebody would be getting sick, somebody would go going to the hospital or something.

And essentially what the community has said is.

You, they, they put social distancing and other things in place, but they haven't shut down those activities. But they say, you know, the, the minute we have one, we're gonna shut down those activities. Um, and, and so you would think we'd have something and anyway, yeah, it's, it's, it's a tough one. Um, like I said, in the community where we were, we thought that it was totally, uh, isolated.

Protected, and wasn't going to have a case. And then it did. And then, then the question is, you know, did you take the, uh, by having the activities, did you take the Trojan horse into the city wall and say, we're gonna push it out Once we prove there's Trojans in it, you know, the, the, the damage might be done if you wait for it in a population of senior citizens.

Yeah, this, so this question's coming up, uh, more and more, which is, you know, we seem to be measuring this disease based on cases, not on deaths anymore. And, you know, we talked about flattening the curve and that was the whole thing. We're gonna flatten the curve. And so now we're getting on the other side and people feel like the, the goalposts have moved.

Um, and the question really is, you know, do we track the flu based on cases or do we measure the flu based on, uh, again, how lethal it is and how many deaths come about from it. Yeah. And, and with the influenza seasons we always look at the total number of infected, um, you know, 29 million, et cetera. And then we look at the deaths 30,000 average per year.

And we track that. And yet we've never responded as strongly. Um, we in fact have inadequately responded to influenza over the years 'cause we really could mitigate that more with better immunization since we do have, um, vaccines for it. Um, and better hand washing, which now maybe we're all good at 22nd hand washings.

Um, but our flu seasons could have been better than they've been. And we've been rather cavalier as a nation, but also as a world about influenza because it's been around and we're reacting really strongly to this. It's new. Um, there's some reasons to strongly, but maybe there's. That balance between mitigation and elimination of risk has to be struck.

We cannot eliminate all risk in life. We can mitigate how much mitigation is tolerable and sustainable. That's, you know, that's an argument for a lot of folks smarter than me and a lot of folks who understand the economics better than I do. Uh, but you do have to strike a balance at some point. Yeah. And so that's where we're gonna go next.

So I, this, this act, this question's actually from me. So I spoke to a health system. Uh, that has their, or functioning at about 50%, losing a fair amount of money every month, and there's no option for them to really reopen it at full capacity due to government restrictions and other things that they have to, uh, get through.

But the reality is they have one positive Covid case at the hospital. And, you know, we're in the process of bankrupting hospitals for one case of covid. Does that make sense? Yeah. And, and it doesn't. It does. It doesn't. It doesn't. Until it does. Yeah. It, it doesn't. In that, that case makes a very good argument for let's go business as usual and survive so that we can take care of all these other things that we're currently ignoring and pushing down the way.

'cause we're gonna see cancer diagnoses, rates, et cetera, spike, post Covid. Um, but it does make sense because we were not prepared. Manage this. And because of the structure of our healthcare system where it is a competitive environment, if you have four hospitals in a community, um, none of the four from different systems is gonna jump forward and say, Hey, make me the Covid Hospital.

We'll take all the covid cases, triage 'em elsewhere, dump 'em on us, we'll shut down everything. And you guys go. Well, you could do that and you would've thought it might've happened in Italy because Italy has a national system and regionalized, uh, hospitals and they didn't have it prepared. And to go forward, I think we're gonna have to think about can we designate places to be the infectious disease almost back to the sanitarium days, except for when they're not sanitariums, they have to be fully functioning hospitals.

The of us support that hospital that serves as the sanitarium so they can be back on their feet when the crisis is over. That's, I think, gonna be something that policymakers are gonna really have to discuss is how do we. Restructure our health system and our utilization of bricks and mortar resources in the US to allow us to respond to something like this without this draconian shutting down of every single site to the impairment, not only of their financial viability, but to the impairment of the population.

People not getting screen for cancers, not getting screened for diabetes, not getting screened for cholesterol. Saw the numbers that came out. New York, you know, 60% on some things, 90% reduction in in other areas because engaged.

So, you know, again, some of these I, I struggle to even read because I know that people are gonna have when I read, but, uh, but essentially, you know, we shut down the economy. Uh, 30 million people have lost their jobs. 2 28. Health systems have furloughed employees. Uh, we have the USA today talking about the hundreds of rural hospitals that will likely, uh, just close and cease to, uh, we, we've sent people home and told them, uh, they really can't go back to work.

And, uh, we've, we've really created a Petri dish for domestic abuse, depression, mental health issues, uh, as well as some of the things you're talking about. We're not doing screenings. Uh, there stories now of people literally having strokes at home because they're afraid of going into the hospital, uh, and getting covid.

Um, you know. Does, does that make sense? Is there a way to do this where we're not creating this, the, the significant problems on the other side of this? Yeah, and again, un unbelievably complex, you know, I used to talk about complicated was a internal combustion engine. It's a lot of parts and a lot of things, but an individual could actually learn to take apart and put back together an internal combustion engine and know how it works.

One person could do that. One person can deal with a complex system, and I think that complexity means the conversations are gonna have to be carried out around how do we help the system to move forward, restructure so that we don't have to shut everything down in the future. And. Reduce some of the anxiety provoking and sensationalizing that we've seen across media in every direction.

Um, you know, if, if, if you show us only the worst and you show us scary, scary things about hospitals and we see the Elmhurst Hospital over and over again, I'm not going into that hospital if I'm a well patient otherwise. And yet we have to have people go into hospitals. It is much more dangerous to stay at home with some facial weakness and slurring a speech than to go to a hospital.

Intellectually we know that, but now we're at an emotional state. We have to help people come back to a less emotional response, and that's really hard, but we have to be able to say, yes, this is new. But no, this is not different than other things we. It does not eliminate all the other series health issues that we should be attending to.

How we do that, that's, like I said, incredibly complex. I think the AMA is joining into conversation quite well. I think the other organized medical groups are, I think a number of our states, the state leaderships are, we need to have the conversation and unfortunately, in the midst of an epidemic, it.

Conversations. We are making decisions right now that we would never make at other times, whether it's for patient privacy or for accepting tests that are inadequate. Um, we just wouldn't do some of these things in normal times. When we get to a point where we can take a breath, the conversations have to continue and unfortunately we have a history of going, got through that and.

Yeah. Uh, so I'm gonna have two questions and thanks. Thanks. This, you know, there's, there's no doctor patient visit where you're.

So this is, this is pretty normal. Well, you know, this is pretty normal. That's why my, um, CMA was always at the door knocking, saying, Dr. Bens, you have a phone call, , just to try to get me to cut off . So, alright, so lemme know when, when the, when they knock on the door over there. Um, so let's talk, you know, contact tracing and testing seems to be the playbook that the medical community is, uh, throwing around, and the only rational approach for containing the virus.

Bipartisan, uh, contact tracing testing. The, the question really is, uh, with a million confirmed cases, isn't containment a lost battle already? Why? Why would I give up any semblance of privacy for a cause that is lost to begin with? Yeah. And so containment is already a lost battle. Um, you right. But the reality is if you.

In fact can get it to start to decrease a little bit. Contact tracing is what helps you prevent the spikes on the go forward. And so I think contact tracing has a real place. You know, if we were New Zealand, it'd be a little more obvious of a case. They've supposedly eradicated new infections at this point.

If they see something, then contact tracing would really help them to contain. But even with a million confirmed cases, you can contain further spread by contact tracing and being able to get the testing out and then quarantine those who, um, have been exposed and treat those who've been, um, test positive.

Treat, which treat is currently only supportive treatment. Right. We don't have any actual treatment. Um, rem um, REM has some promise, but it's, you know, there's, there's a lot of, um, questions about how effective that is. Uh, but contact tracing, um, is a way to. From coming control the resurgences that, um, we now anticipate are gonna continue over two years or until we have an effective vaccine that is highly penetrated.

All right, so you said two years, which leads to the, the final question, which is, you know, we we're saying terms as a, as a society now that we, we didn't even know back, uh, you know, four months ago, which is herd immunity. So we hear this whole concept of the only way to get to the other side of this is through it, right?

To get enough of the population. Uh, has either, you know, recovered or has some semblance of the antibodies built up, uh, within them. And there's a couple ways to do that. I mean, you have the, uh, now famous, I guess Sweden is, is heading through it. Just, you know, they haven't closed their schools. They're, uh, they're practicing social distancing, but they're doing it at a different level than most others.

They're saying, we're.

And so, but the, the other side of this in the US is we keep hearing, uh, you know, a year and a half until we have a vaccination. And you know, I hear the word two years. I hear a year and a half till we have a vaccination. I hear the only way through this is herd immunity. And I go, are you kidding me? Are we gonna live like this for the next two years?

And is that even possible? Um.

Uh, is that the case? Is the only way through this that enough of the community builds up an immunity? And what does the path look like to get from here to a point where, uh, we have enough immunity built up within our society? So if you go the herd route, um, without a vaccine, um, it looks like the total number of deaths that was originally projected.

Um, and that's in the, uh, millions. One to 2 million deaths across the us um, and you could get to herd immunity. The question there, and the one I don't have an answer to, and I haven't seen an answer in the literature yet, is having gotten through that and essentially sacrifice that many, uh, individuals in our population to get there, would you actually have immunity?

We don't know that yet. That's.

Actually grant immunity for an individual. So then the next part is can you sustain this for 18 months? I think because we have such variable approaches, we're going to continue to have the huge amount of contention. Um, I think change facilitation. I always hate the word change management 'cause that still implies that I'm controlling you.

But change facilitation me helping others to understand that simply wearing a mask, um, went out in public and keeping social distance. Can allow us to get back to a lot of activities, can allow us to restart the economy, uh, putting in place some of the, um, barriers, et cetera, at workplaces to protect workers can allow us to get back there.

And I think that's how you get through the 18 months is with those measures, recognizing they're imperfect. And that's where contact tracing then comes in. So you can, um, have some further mitigation behind that. The real question is that's expensive. That daily cleaning in everyone's office, in everyone's store, that's expensive.

Uh, PPE, expensive, and those are added costs of doing business at a time when you're making less revenue. And how do you get through that?

Those are big questions and like I said earlier, it's gonna take a lot of folks a lot smarter than me, but with a calm voice and with a real desire to help and a real desire to engage everyone in helping. 'cause I don't think this is something you get through with directives or with, I know better than you.

You do what I say, type approach. You know, we're gonna just stick our head in the sand and it's gonna go away approach. Neither of those works, but how do we engage each other and really, um, appeal to our better angels to do what's best for one another? Golden rule still applies. Yeah. You know, as is usually the case with you and I, um, we're, we're gonna end this episode because it's coming up on, on, uh, the max that we like to do for an episode.

But, uh, you and I are probably gonna talk for another half hour on this, on this topic, uh, because you know what, it's, and I really appreciate your time today and talking through this and this.

I mean, people are talking, but no one's really listening. We've set up sides on this. You know, on one side, uh, you, you, uh, trust in science. And on the other side, I guess if you don't trust in science, you're just, you know, you're, I don't know, ignorant. And, and the social media posts almost come off as that it's so divisive at this point, and it makes the, the situation that much harder to try to get a cohesive strategy across the board.

It's impossible to answer when. All the planes are gonna be back in the air. And when I'm gonna feel safe getting on a, a fully packed plane, or when I'm gonna go to the next, you know, baseball game and sit in a, a crowded stadium. Those are impossible things. And those are probably the last things we're gonna see in this.

Um, but on, on the flip side, I, I feel the pain of some of these social media posts. I mean, the, the, just the, you know, I've been furloughed. Do you see a future where I get brought back and um, and we don't have answers right now for that, but I wish we would at. As we're trying to explain the, the, uh, the serious, uh, seriousness of the disease and the potential ramifications of just ignoring, uh, the, the, the medical community on some of these things.

It's, you know, we, we can find a path through as long as we're gonna.

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