Excellent COVID-19 resource for decisionmakers at various levels

I started attending various webinars some time ago, like lots of people, and like lots of people, I also got a little webinar fatigue at times.

A great series continues to be organised by the National Academy of Medicine and the American Public Health Association in the US, looking into many topics such as the science of the virus, finding vaccines, health inequalities and so on.

Today’s session, on mitigating direct and indirect impacts in the coming months, was excellent for decisionmakers at all levels – also in the UK! – because it addressed a lot of practical aspects and many angles of the pandemic.

It mentioned the need to provide free wifi, talked about telehealth (telemedicine) and developments expected to take a decade suddenly being realised in a mere three weeks, about the complications food deserts pose, about the politicizing of the pandemic, about how to cope with emergencies such as hurricanes and related evacuations, how to remedy the impact the pandemic is having on non-Covid-related healthcare (such as people with heart attacks not seeking help out of fear of catching the virus), the healthcare clinics getting into financial difficulties as a result (as, I think, we saw earlier with those two doctors in California who owned a small chain of facilities and saw their turnover drop so dramatically that they resorted to unorthodox action), the challenge and need to communicate well and perhaps have ambassadors explain the purpose and reasoning behind social distancing, the massive impact social distancing has on the infection rate and the risk of people that people will no longer observe distancing when lockdowns are relaxed and developing a false sense of safety, and so on and so forth.

Here is a link for a model (simulator) that people can play with to explore the effects of lifting lockdowns: https://budgetmodel.wharton.upenn.edu/

The video recording of the webinar will be online soon, at covid19conversations.org:
https://covid19conversations.org/webinars/summer.

The slides have already been uploaded, but not all presenters used slides and the Q&A of course is not online yet either. I’ll post the unedited transcript below.

22:00:37 Starting the broadcast now. Hello I’m Dr. George — I’m the American
22:00:45 director of the American health association. I want to welcome you to to COVID webinar series brought
22:00:53 to you by the national academy of medicine and I would like to thank my cosponsor Dr. — President
22:01:02 for the strong support of this important effort. We are grateful for the expert advisory
22:01:11 group which is cochaired by Dr. Carlos an Dr. LURIE you can find all of our advisors listed at COVID
22:01:19 conversations.org. We are also grateful to this series because it is designed to explore the state
22:01:27 of the science on COVID 19 to inform policy makers, public health and health care professionals,
22:01:34 scientists, business leaders an the public at large. More information on the series an the past
22:01:41 webinars are available at COVID 19 conversations.org. Now today’s webinar has been improved for
22:01:51 one and a half continuing education credits for chess, C M E and C P H. None of the speakerring
22:01:58 has any relevant financial relationships to disclose. I want you to please note if you want continuing
22:02:04 education credit you should have registered with your first and last name. Everyone who wants credit
22:02:11 must have their own registration and watch today’s event in it’s entirety. All of the PARTICIPANTs
22:02:19 today will receive an e-mail within a few days from CPD at concepts.com you can look for that. That’s
22:02:26 CPD at confects.com and it will have information on claiming your credits. All on-line evaluations
22:02:34 must be submitted by June 26, 2020 to receive the continuing education credit. Of course
22:02:40 if you have any questions on topics that you like to address today or on future webinars please
22:02:51 enter them in the Q and A box on your screen or e-mail us at APHA at APHA.org that is APHA at
22:03:00 APHA.org. If you experience technical difficulties doing this webinar please enter your questions
22:03:07 in the box but please pay attention to the chat for how to troubleshoot. Again, if you have any
22:03:14 questions please pay attention to the chat box or we continually put information in there on how
22:03:20 to troubleshoot. This webinar will be recorded and recorded in transcript will be available on
22:03:31 COVID 19 conversation conversations.org on the website. Now I would like you to introduce the moderator
22:03:40 Dr. Nicki LAURIE is a former secretary for the Department of health an human services during
22:03:47 the Obama administration. In that position Dr. Laurie over saw the federal public health response
22:03:55 to various health cries IS including hurricane Sandy an the Boston marathon bombing, Nicki I will
22:03:58 turn it over to you today to frame our conversations.
22:04:09 >> Thank you so much and hello to all of you. Memorial day marks for most of us sort of the notional
22:04:16 beginning of summer. This is the summer when none of us have much of an idea to expect. We do
22:04:23 expect warming weather with this comes all kinds of weather events. Tornadoes hurricanes and this
22:04:30 time well we have been hoping that COVID 19 might just burn out over the summer. It’s not yet
22:04:37 showing signs of doing this. We are looking at loosening restrictions after months of
22:04:42 stay at home orders. I think we saw evidence of some of that behavior over memorial day week end
22:04:50 and you know there’s a lot of pent up activity on many many fronts. We are also looking at
22:04:56 thinking about how the economic recovery gets stimulated. A lot of things can come together
22:05:03 this summer that are hard to anticipate some of which we really need to think about now in advanced.
22:05:10 We thought it would be useful to put together a webinar to explore the issues for combination of short
22:05:16 presentations and a panel discussion. I would like to start by introducing our panelist briefly.
22:05:26 I think the bios are available to you but kent is the chair at the University of Pennsylvania and
22:05:36 a fellow of at the economic research among others. He’s the faculty director of pen’s war ton.
22:05:45 CBO spent time at Stanford and been a deputy assistant secretary of the U.S. treasury. A chief of
22:05:50 long time colleague of mine associate professor in the Department of health care policy at Harvard
22:05:57 medical school an a physician at the medical senator. His research focuses on evaluating the impact
22:06:04 of delivery innovation such as tele medicine which we have seen a ton of in this pandemic on cost
22:06:10 quality and access in the U.S. health care system. He received his medical degree from the University
22:06:17 of California San Francisco and completed his residency in pediatric at mass general an Boston children’s
22:06:25 hospital. Craig FUGATE ask a colleague during the Obama administration was a phenomenal FEMA administrator
22:06:35 from May 2009 all the way through the 2017. Prior to that he served as Florida governor emergency
22:06:44 management director and also served with governor Charlie Chris from 2007 to 9. He led FEMA not
22:06:55 only through multipal record breaking disSA*DZer years and, too many to mention events, but he was
22:07:05 a real voice for innovation and sent a clear and compelling vision, mission and priorities for FEMA.
22:07:12 Rerelent lessly to achieve better outcomes for survivors. He’s somebody that I really
22:07:22 came to look up to and admire for all of his innovation. Craig as the chief emergency management
22:07:30 officer at one concern about continues to do consulting a whole variety of issues related to disaster
22:07:41 preparedness an response and finally past President of APHA and the gun violence prevention work
22:07:49 group. She’s the lecture of adjunct professor at the roll lins school of public health at Emory
22:07:58 and a member of MNAM. She previously served for the national center for injury prevention at CDC
22:08:09 and was in a number of other roles and she’s an a native of Chicago and has her degrees from dePaul
22:08:16 University an PH from Yale and was at Robert Johnson health policy fellow in the office of my former
22:08:24 senator. Senator Paul well stone and that’s where I met Linda actually it’s a great group
22:08:32 of people an thank you for all being here. I am going to go over to professor SMETTERS to get us
22:08:33 started. Thanks.
22:08:46 >> All right thanks for the invitation it’s great to be here and that if you could go to the next
22:08:54 slide. And then the next one. So certainly at one point every state has imposed some type of
22:09:02 lock down orders as you know and most states have started to relax these orders including stay at
22:09:10 home orders and especially on stay at home but also on various nonessential business activities
22:09:15 and of course this is going to have an economic benefit that’s the whole goal of trying to relax
22:09:25 some of these orders but at the same time it has costs an we always have decided they are making
22:09:34 trade offs between the various risks we make and the cost and this case things like cases and infections.
22:09:39 We don’t have a lot of time to talk about the framework we use but at a high level we gather a bunch
22:09:45 of data I usually measure at the daily level typically at the ZIP code or county level on a couple
22:09:52 of cases at the state level. This type of data is not available from the government, some of it
22:09:58 is like weather data but a lot of it is not. A real kudos to a lot of private company’s that open
22:10:06 up their data an everything from cell phone location that is we get to figure out or encounters
22:10:15 to employee scheduling software firms so we can see businesses that are opened and close even how
22:10:21 many people they are employing an how many hours people are working and certainly initial claims
22:10:27 an web searches an lots of financial data and so forth and of course what we do get from the government
22:10:34 is climate data as well as some county level demographics the age composition of the population matters
22:10:41 the labor force composition that we are talking about that the dense financial service city or are
22:10:49 we talking about Wyoming with more just kind of natural social distancing maybe more agriculture
22:10:56 an we put this, these data into an academic framework that does a measurement of social distancing
22:11:02 of other key factors associated with all of these different things the population the type of work
22:11:14 and so forth. That feeds then into the epidemiological model that the standard framework.
22:11:19 We don’t have time to go through all the details but as you probably know those of you with a background
22:11:27 that the reproduction number the R R notes is really a key number in particular in terms of cases
22:11:34 and the spread and it’s really the most important number even more important than the fatality rate
22:11:41 in these models, so next slide. So what we do with this is that because we are not running just
22:11:52 two miles separately it’s the economics are determining the, the things like R not in epidemiological
22:11:59 variables so they become inputs into epidemiological variables. What the model does it basically
22:12:04 gets us away from sometimes called the hammer and the dance. The hammer is of course we see cases
22:12:11 going up at an exponential rate we put the hammer on the quarantine the stay at home orders then
22:12:16 there’s this dance that we start to lift them up but we can’t do it in a continuous way, we kind
22:12:22 of dance an hope the cases don’t start to explode again an so forth. The point of this framework
22:12:31 is to be more perspective rather than adapt i my KWROPic crutch where you are only using epidemiological
22:12:37 model. You can play with the model YOURSELVES it’s a similar interface. Let’s go to the pen war
22:12:43 ton budget model website. You will see the link there and you can look at your state an do different
22:12:50 type of policies and scenarios an summarize. We will talk about you know you can drill down into
22:12:57 your state an play movies to see how things are changing over time an so forth. The next slide.
22:13:02 Estimation strategy it’s got a little squished. The estimation strategy we don’t have time to go
22:13:10 into a lot of detail the key about it we need to separate cost and effect and in particular one
22:13:17 technique that we use is what’s called principle components analysis. This separates out things
22:13:22 for example some models have claimed that there’s a big weather effect and of course we even pick
22:13:31 up a weather effect that’s true some of the weather fact that’s picked up some type of epidemiological
22:13:38 models it’s also coming from older city’s that happen in the northeast and Northern part of the
22:13:43 country those also tepid to be more dense and so we really need to separate density from weather
22:13:49 and principle components analysis that’s kind of the leading way to really do that and then we use
22:13:58 what’s called across time this ask a fancy language that it kind of emits will use to say we really
22:14:05 do need to figure out and distinguish between cause an effect just because a state clamped down
22:14:14 and they have an impact in cases or were they clamping down in response to cases. There are some
22:14:21 heterogeneity there’s some more states be blue or red states some states have different social attitudes
22:14:28 for this and that will allow for timing differences an allow us to identify actually sources,
22:14:35 a change in the policy so what we don’t want to deal with is simply just a look at levels an extrapolate
22:14:44 out levels we really need to figure out the cause and effect. That requires all of this more data
22:14:50 and really made it a level to do that so next slide. So how again, we have a lot of time to spend
22:14:59 on this how we validate a model like this. We want to see if the model is properly set up an properly
22:15:07 calibrated before the period where the policy is changed and that’s that vertical I can’t control
22:15:12 the mouse but if you see each one of those boxes that you have this line that’s going down the middle
22:15:27 of the box. That’s a prepolicy period and the right hand side is the post policy these are different
22:15:36 way that is governors have done school closures an so forth. Most of the stuff is random around
22:15:43 zero there’s no specific trend around zero and then in the post policy period that’s where we will
22:15:49 see the trends an we see it actually emergency declarations themselves we are not terribly effective
22:15:55 and reducing social distancing the reason why they are vague they didn’t really by themselves do
22:16:03 much. They mainly unleashed the various laws around price controls an price gouging and freed up
22:16:09 resources they didn’t do much about social distancing or social stay at home orders big impact
22:16:18 school closures certainly had an impact and restaurant restrictions did. We saw it before policy
22:16:23 came in while people were already going to fewer restaurants an so forth. That’s the reason why
22:16:29 we need to do all of these controls to make sure that we really are SAOEUFing that out and separating
22:16:34 that out and saying hence when you see restaurant restriction there is you see the prepolicy
22:16:41 period it’s still randomly distributed around zero we are causing the cause and effect. It’s picking
22:16:46 up a trend that otherwise would have happened an other things. So when we go to the next slide.
22:16:56 This is the SEIIR model. It’s been around for a long time. It’s first form was the SIR model
22:17:03 susceptible infected resistant and then some years later the exposed layer has been added and as
22:17:09 you know everybody almost everybody susceptible not everybody is exposed and what became really
22:17:17 important for COVID 19 is the fact that as you know asymptomatic transmission is potentially a big
22:17:25 deal they infected part we split out between the systematic population an asymptomatic population
22:17:30 that all has to be calibrated and so forth. There’s actually no question if you look at the U.S.
22:17:37 data there’s so much sample selection in it and you know there has to be a lot of cleverness in how
22:17:44 even how we measure case to value rates there’s still a lot of uncertainty about what the case fatality
22:17:50 rate is so forth. It turns out this R value is the most important one we do a lot of SENSITIVITY
22:17:55 analysis around that. None the less the United States is not set up in a way that collects data
22:18:04 and in an unbiased way and right now. So why don’t we go to the next slide. This R this R value
22:18:10 I should point out because I am being this presumption, the R means it’s a replication factor
22:18:19 and it’s on average how many people does an infected person in turn effect. R two or three means
22:18:26 an infected person on average is going to infect two or three more people and so the goal is to get
22:18:34 R below one. R above one we run the explosive path on infections. It means in fact that we will
22:18:40 be nonexploding path and so the whole goal they eventually get R less than one. We see that in
22:18:48 a lot of states both policy and prepolicy the R is been coming down and some states are still above
22:18:55 one Wisconsin, Maryland and so forth are still above one so that will be a challenge as they begin
22:19:03 to reopen. The next slide and here’s the bottom line numbers this will be my last slide here.
22:19:09 In particular so what this experiment does this is just for the United States you can go to the website
22:19:18 an pull it down for your state. It looks at two different types combinations mere. One
22:19:25 is the policy scenario an baseline is so this knewest production I forgot to write this on the slide.
22:19:34 The newest production is May 26 an July 30th and so we update every Monday. So what this baseline
22:19:42 policy means is that whatever policy the state has as of May 25 they keep that policy going up through
22:19:49 end of July 30th and behavior scenario is that people whatever people are currently doing in that
22:19:54 state in terms of social distancing it will varyly state by culture by other factors whatever you
22:20:00 are doing in that state it’s at the county level that we aggregate up they continue to keep on doing
22:20:09 an we are projecting by end of July there will be about 2 P*BT 7 million cases 153, 000 deaths.
22:20:14 Unfortunately our death productions have been accurate so far an that’s unfortunate because they have
22:20:21 not been I have had many friends say they disconnected from me on social media because they were
22:20:28 — by the death projections but so far they have been tracking what’s actually happening. So we
22:20:36 are also forecasting there will be of the 33ish million jobs that have been lost 1.6 will be recovered
22:20:43 an the last column is actually I can’t see it on my SKRAOL the year over GDP. It’s saying that
22:20:56 GDP will be about 4.3% lower than it was on July 30, 2019. If we lift the stay at home
22:21:01 orders which are the remaining the personal behavior doesn’t change. It has variable effect that’s
22:21:09 because what happens is that most states are already lifted their stay at 40E78 orders there’s only
22:21:15 a few state that is haven’t lifted stay at home orders it doesn’t have a huge impacts. A full reopening
22:21:24 will increase deaths by 43, 000 and will increase 800, 000 cases I shouldn’t say will but that’s
22:21:33 what we are projecting but it will also recover about 8 P*BT 8 million jobs just to be clear that
22:21:43 is jobs over the forecast window that won’t mean that we will go to a prepandemic level additional
22:21:50 8 P*PT 8 it will eat into the 33 million jobs that we have lost and reduce the job loss. This is
22:21:56 a big take away supposed people take this policy change as a cue that things are okay
22:22:02 so they reduce their own personal social distancing they are not staying six feet apart and they
22:22:07 are not wearing masks an they are in larger groups. This is what we call it had reduced social
22:22:14 distancing. We are not saying this is going to happen instandpointly if it follows a log scale.
22:22:20 A lot of it happens in the first couple of months. Schools are on break during the summer. If in
22:22:27 fact we go to reduce social distancing that has a much bigger impact in cases an deaths for example
22:22:35 if states do a full reopening we project deaths go up by 43, 000 by enof July. If they
22:22:42 were do that at the beginning oh of this week an continue that by the enof July. If fact people
22:22:50 reduce social distancing deaths go up by 400, 000 plus. It AO ES the personal behavior that is
22:22:57 more important that policy. The personal behavior is super relevant here so thank you.
22:23:07 >> Thank you thank you so much for that that is quite a sobering assessment. And set of projections
22:23:14 that we have I think it really also points to the kinds of education and messaging challenges
22:23:22 that we are going to have over the summer in terms of helping people understand the importance of
22:23:30 the kinds of personal behaviors to limit the spread but at the same time try to help the
22:23:37 economy recovery. Maybe during the panel discussion we can talk about those more dire projections
22:23:44 and what might happen to the economy if we have that much uncontrolled spread in excess deaths past
22:23:56 your window. In the meantime why don’t we turn over to Dr. — to talk about managing the health
22:24:04 threat to nonurgent care you know we have heard so much about anything from kids missing immunizations
22:24:14 to delays in elective procedures I am eager to hear what he has to say, ATIF MEHROTRA.
22:24:22 >> Okay great. Next slide. I am going to talk about the focus not the economic and health costs
22:24:27 of the virus but to be more broad and talk about the nonCOVID related care and how American’s
22:24:34 have changed their behavior during the pandemic in getting that care. Why
22:24:43 do we care? The first is it really helps to quantify the clinical or health impact of the pandemic.
22:24:48 Highlight a concern that we have that one of the impacts of this pandemic is that many patients are
22:24:56 dying not because of the virus itself but rather because they are not getting the health care they
22:25:06 need. We are also critically it matters greatly because it matters upon the economic impact on the
22:25:12 pandemic. This potential paradox we might face which at the same time so many people are becoming
22:25:19 ill in the United States and seeking care for the virus at the same time health care providers are
22:25:27 struggling financially and many might go out of business, so the next slide. So what has been the
22:25:33 impact of the pandemic on the number of visits in the United States? What we are showing you here
22:25:42 is on the X axis is the number of visits per week to roughly 50, 000 health care providers from
22:25:48 across the nation. What we are showing you here as a percentage change from the baseline prior to
22:25:55 the pandemic and specifically the week of March 1. Before early March we have you know the same
22:26:01 number of visits they were around the same and then starting in the week of March 8th and progressively
22:26:09 through the week of March 29 we saw a rapid and dramatic decline in the number of visits both
22:26:22 tele medicine an in person visits in the United States. A 60% decline by early April. We have been
22:26:28 following the visit trends of this month. The week of May 10 we started to see a bit of rePWOUPD
22:26:37 in the number of visits now the visits are down 60% they are down roughly 30% they are substantially
22:26:44 down but a bit of a rebound. One of the things that all of you on the phone on the webinar as
22:26:52 well as American’s are you know doing for the first time is Nicki mentioned is tele medicine. We
22:27:01 are and we are getting care in a very different way of via video or the via the phone. What this
22:27:07 graph shows you is that in number. We are showing you the percentage of all visits prior to the
22:27:14 pandemic and how many are being provided by tele medicine. There’s a dramatic time in overall
22:27:20 visits. We saw a big rise in the number of visits provided be I a tele medicine rising perfectly
22:27:27 by mid April up to 14% baseline visits to give you a sense of what that means there’s roughly about
22:27:33 a billion office visits per year in the United States. If they project out for 12 months there would
22:27:41 be a 140 million visits by tele medicine obviously a big change prior to the pandemic. Next slide.
22:27:47 I want to clarify that yes tele medicine business did rise but they only partially offset
22:27:54 the drop in inperson visits this graph goes back and this is the blue or turquoise line that we saw
22:28:00 previously was the drop in all visits in orange I’m showing you the decline in in person visits
22:28:06 that gap between the two lines is the tele medicine it only partially offsets the drop so we can
22:28:16 see. Next slide. That’s overall what we have seen is very different reactions, different visit
22:28:22 patterns across the clinical specialties. So in orange I am showing you here the percentage decline
22:28:30 in overall visits in the week of April 5. You can see for some surgal specialties the decline in
22:28:38 visits was much greater more than 70% if you go the area behavioral health and endocrinenology you
22:28:44 are seeing less of a decline that’s really relevant to the clinical impact as we are seeing more
22:28:51 and more patients suffer from anxiety, depression, TKUR the pandemic and can they get the care they
22:29:00 need. Next slide. How does this vary by age group. If we focus on the origin lines we see the
22:29:05 greatest decline among children those between the ages of 3 an 17 in particular are school age children
22:29:12 as well as those adults greater than 75. Obviously that also in particular for that oldest
22:29:19 age group is very concerning given that’s where the highest burden of chronic illness is. The next
22:29:26 slide? So why should we worried what do these visits trends tell us what should we be worried
22:29:32 about in the coming months. As I indicated before there is substantial concern that patients
22:29:38 are dying not because of the virus but because they didn’t get the care they need. Folks have talked
22:29:46 about a potential second pandemic of patients being hospitalized because their heart failure or
22:29:53 asthma or COPD was not well managed. When we think about the global impact of the pandemic we
22:29:59 need to consider those issues, go to the next slide you know it’s interesting two days ago
22:30:06 the New York times had a nice piece describing how patients are scared to go and get health care
22:30:11 anywhere ranging from patient who is are refusing a transplant to other types of care an two quotes
22:30:19 jumped out at me if you can click again. One doctor prescribed I am having a heart attack I am
22:30:24 going to stay home I am not going to die in that hospital. That quote is reflected in the data
22:30:30 where we are seeing roughly 50% declines in the number of patients coming to the hospital with
22:30:36 a heart attack. Let me be very clear staying at home with a heart attack is very dangerous an life
22:30:44 threatening. It could lead to arrhythmias an sudden cardiac death. I am very concern it’s some
22:30:50 evidence that patients had died at home because they did not get care. I get it I understand why
22:30:57 patients are scare to get in. One person told the Facebook group every time she has to go in for
22:31:03 scan or blood work she has a borderline melt down she’s scared to get the care she needs. Next
22:31:12 slide. We are worried about patients dying because they didn’t get the care. We are worried
22:31:20 a potential second pandemic. We saw a dig TPHEUF can’t declines in the number of children.
22:31:27 That means fewer children many of you heard pediatricians that children are not getting the immunizations
22:31:34 they need that’s going to have significant impact as we move forward in terms of say another measles
22:31:42 out PWAEBG. I eluded to the fact that the pandemic the stay at home have led to parents having
22:31:47 suffered from mental illness such as anxiety or depression. Can they get the care they need when
22:31:56 they are having such a global decline in visits. Last and equally importantly as I indicated a
22:32:03 paradox that despite all of these patients needing more care for the virus this huge drop in visits
22:32:10 that I am describing to you led to substantial financial strain on practices. We have seen health
22:32:17 systems cut salaries an tremendous amount of furloughs an much of increase in unemployment is surprisingly
22:32:24 coming from the health care industry and lastly if those in the coming months if those practices
22:32:31 have to go out of business then that’s going to even worsen the strain on the health care system
22:32:38 to absorb the care they need to provide. So I end there and I look forward to the Q and A.
22:32:47 >> Thank you so much again, continued sobering assessments of what is going on here. Well as we
22:32:58 mentioned it’s summertime and hurricane season and you know quite a — no stranger to managing many
22:33:10 current strategies we look TPW-RD to managing current emergencies in the summer of COVID. I know
22:33:16 it’s one of the things that’s been highlighted in the past few days. We are likely to have a worse
22:33:24 hurricane season this year. Many people who typically volunteer are older people and thatry
22:33:31 are at particular risk if they volunteer in settings where COVID transmission is likely, so eager
22:33:35 to hear your thoughts an approaches to this?
22:33:42 >> Thanks Nicki and good afternoon everyone. Disasters won’t stop for a pandemic we know that and
22:33:51 as we are preparing for hurricane season we already seen dam failures, floods, tornadoes and in
22:33:57 a forecast also for active wild fire season. I think a lot of people throw their hands up in the
22:34:03 air and say how do we all do this for emergency managers it’s not an option. We are going to have
22:34:11 to address it. So why is a pandemic so much different than the other disasters and I think this
22:34:17 is it helps us understand what we are dealing with and pandemics as well as things like cyber attacks
22:34:25 an climate are not geographically based there’s no border. Most disaster responses in the area
22:34:32 it’s impacted. We will pull resources across the nation and some cases across the world to respond
22:34:40 to that event. Well, in a pandemic particularly with COVID 19 where people are the vector moving
22:34:48 people either to respond or Nicki pointed out volunteer S-S a risk that we are bringing more people
22:34:58 into an area where either they maybe introducing further spread or they maybe becoming exposed
22:35:05 and bring it back home, so that’s our first consideration. The second consideration is a lot of
22:35:11 our mass care activities to take care of the public evacuations sheltering feeding operations are
22:35:18 also potential amplifiers of spread of this virus, so emergency managers have been looking
22:35:24 at this and planning for this and there are some we think rather straightforward solutions. They
22:35:32 are not perfect but they are answers to this question how do we respond effectively while minimizing
22:35:41 the risk of further spread of COVID 19? The first will be again, for our responders ensuring that
22:35:47 they have protective equipment that we are deploying them in a way that minimizes their exposures
22:35:54 and keeping team that is are coming in from the outside and separate from other teams to not comingle
22:36:00 teams and this May mean that we will have to set up more areas to house worker that is are separate
22:36:08 instead of one large base camp this is consideration being made for the wild land fire community.
22:36:15 The other is the responders themselves the volunteers. If you think about what we see in disasters
22:36:23 from red cross and salvation Army and team RAOUB con and you know a variety of organizations is people
22:36:30 traveling from all over the country to help provide mass care. That might not be our best option
22:36:36 this year. Our best option maybe with oral central kitchen an other organizations some of which
22:36:43 are using FEMA funding an instead of bringing volunteers in to prepare meals for people during a
22:36:50 disaster we hire displaced food industry, restaurants an other that is are now just starting to
22:36:57 open are still way under their capacity an by putting people to work in a disaster area particularly
22:37:04 those locations in restaurant that is are able to get open we can perform many of our mass care functions
22:37:11 by putting people back to work. We still have very large unemployment numbers our hospitality
22:37:18 industry is been one of the most adversely effected and these are things that eligible for reimbursement
22:37:26 by FEMA in a disaster. I think we need to look more at buying our supplies and capabilities locally
22:37:34 and putting people to work and not be dependent on volunteers particularly going, the numbers that
22:37:41 we May need in things like hurricanes and on the other side of that will be the evacuation an mass
22:37:49 care. FEMA, the American red cross and the national organization on volunteers have been working
22:37:56 on national mass care strategies for some time. This year they have updated all in their plans
22:38:06 to look at incorporating social distancing and other practices as required to manage COVID 19.
22:38:14 And no secret to anybody we know that shelter operations will be a high risk factor and two of the
22:38:20 key ingredient that is will determine the risk of the shelters is how many people for how many days
22:38:28 during that shelter could result in explosive numbers of exposures to any people in those shelters
22:38:36 that they are exposed to somebody. With asymptomatic patients an not adequate and enough testing
22:38:45 to test everybody going into the shelters it will be of concern. There is another option and that
22:38:54 is many areas that are in coastal evacuation zones are also seeing even with the reopening significant
22:39:01 vacancies in hotels an motels and as a first line of shelter operations particularly in small
22:39:09 disasters much of the guidance is now suggesting noncongregate care shelter or nonmass shelters
22:39:17 anoutlizing hotels, motels an residence and other activities to hell STER people in smaller groups
22:39:25 while maintaining social distancing. Where we will end up sheltering the goal is to run smaller
22:39:31 shelters. This will require more staffing but again we can hire people in the local communities
22:39:38 to help staff these shelters and also look at running a shorter durations if we see the need people
22:39:45 cannot return home an begin processing those folks to hotels an motels as well. This will cost
22:39:51 a lot more money in the state an local government budgets are under tremendous pressure these days.
22:39:58 The goal is with the federal assistance to help offset these costs an provide the resources that
22:40:05 local government’s and states will need. Again, to summarize if we need to reduce the amount of
22:40:11 people traveling into disaster area we need to treat the people in the area as a resource and do
22:40:19 more hiring and buying local capabilities. We still need people to evacuate. We have to be
22:40:25 absolutely clear on this that we cannot have people so fear of COVID 19 that they stay in dangerous
22:40:32 areas that will be a challenge for hurricane evacuations where historically we have not
22:40:38 had high compliance for evacuation orders an this year with COVID 19 I think that message is going
22:40:44 to be difficult. We need people to evacuate to a safer location and we need to maintain the social
22:40:52 distancing an other tools we know in these shelters and we need to adjust our messages for preparedness
22:41:00 and that is add protective masks an sanitizer an other items to people with disSADZ SAZer kits to
22:41:08 those who have to evacuate. There’s a lot of work being done. We can expect to see disasters over
22:41:15 the life span of COVID 19 and we are seeing those adjustments being made. The last EUB shoe will
22:41:23 be impactses on the existing health care systems. I am less concerns about the impacts on patients
22:41:29 that maybe generated from disaster as much of the requirement to evacuate health care facilities
22:41:37 and disasters such as hurricanes. In Florida we see high levels of incidence of COVID 19 and assisted
22:41:43 living facilities in nursing homes as well as hospitals that are built in hurricane evacuations.
22:41:51 It’s not always the best decisions about siding those facilities. The normal plans are to relocate
22:42:02 them to sister facilities this maybe a very difficult thing to do if we have incidence of spread
22:42:09 already in nursing homes or nursing home facilities an move them to another location
22:42:17 perhaps introducing of another scenario of an uncoTAEUPBed out break. We did a lot of work early
22:42:24 in COVID 19 totem POR rare hospitals they were not aoutlized as there was concern they May need
22:42:33 to be. Those maybe better options to plan for and set up in hurricane prone areas where we May see
22:42:39 evacuations of health care facility that is rather than directing them to go to sister facilities
22:42:46 outside of the area of impact weoutlize the temporary health care facility that is can be set up
22:42:55 and isolate an care for those populations during their evacuations and hopefully manage not creating
22:43:01 further spread of COVID 19 by coMing different populations in these facilities in an
22:43:07 evacuation process. So there’s a lot of work going on and there’s a lot of concern out there but
22:43:13 I think there’s solutions but it does mean we are going to have to think differently about this
22:43:21 and take these lessons an build them into our plans. With that thanks Nicki I will turn it over
22:43:21 to you.
22:43:28 >> Thank you so much I think a really helpful discussion about some you know ways to change our thinking
22:44:14 and some creative solutions here in the face of — and what to expect.
22:44:20 >> Over to you. Thank you for the opportunity to talk about this. I think these are issues that
22:44:26 we have not spent as much time talking about during this pandemic as maybe some of the other health
22:44:39 related issues but certainly something that we need to think more about. I want to define
22:44:45 violence because I think we all have different ways of looking at it. The world HAO*EPLT organization
22:44:55 is intentional use of physical force or it’s against once or one another or group or community.
22:45:03 It results in the injury, death, mall development or deprivation. There’s three type that is we
22:45:09 see and the first two are the one that is we are seeing right now is commonly during the pandemic
22:45:16 there’s the self directed violence which is suicide or other kinds of self harm and then interpersonal
22:45:23 violence and as Nicki mentioned the intimate partner violence that we know increases during other,
22:45:31 that has increased during disasters assaults, homicide, child abuse an neglect. Something that
22:45:39 we haven’t looked as much as but potential or elder abuse or neglect. Next slide. So violence
22:45:45 in natural an unnatural disasters we have evidence that people have been exposed to natural disasters
22:45:53 May developmental health issues post-traumatic stress disorder an depression and anxiety disorders
22:46:02 and increase suicide risk. In a recent study a group looked at low income women and in New Orleans
22:46:10 an looked at them one, four and 12 years after hurricane Katrina. They were looking at what they
22:46:18 experienced and what kinds of things have impacted them in the long term because they had a range
22:46:24 of traumatic experiences. A lot of those are very similar to what we are seeing during the pandemic,
22:46:31 things like grievement, lack of access to medical care, inability to sometimes to get medications
22:46:40 and what this study showed was that during those time periods these exposures that were most strongly
22:46:45 associated with the negative outcomes and negative health outcomes were those most common to what
22:46:52 we are seeing in the current pandemic the psychological distress an post-traumatic stress an general
22:46:59 help and kind of physical inability to go to the doctor or difficulty getting to a doctors office.
22:47:06 And so we know that we have the potential for seeing more of these in the long term 6789 the other
22:47:10 contributing factors for mental he’ll an violence risk with personal threats that someone
22:47:17 feels to their own life that’s certainly the loss of loved ones with this pandemic the inability
22:47:26 to be with them at the time that they are dying or prior to their death and property loss perhaps
22:47:32 from the ability to pay from the economic impactses, some of the break down of social support systems
22:47:39 an social isolation which is especially devastating to older adults and then scarcity of basic
22:47:46 provisions. We have seen scarcity of various kinds of food and powerlessness and the economic stress,
22:47:58 so next slide. So domestic violence we know right now that in about 140 American cities an counties
22:48:05 in 48 states there has been significant increases an calls to domestic violence hotlines an increase
22:48:15 in the month of April was 274% in Alabama. The stay at home orders an lock down have around impact
22:48:22 on people experiencing intimate partner violence because it forces them to shelter in place of
22:48:28 the perpetrator of violence an makes it extremely difficult for someone to leave an abuse i relationship.
22:48:35 In this time period the shelters that’s someone might go to are also raised with the challenge of
22:48:40 providing protection from the violence itself from the perpetrators as well as protection from
22:48:50 spread of the Corona virus. Next slide. Assaults are another issue and we are seeing more an more
22:48:57 assaults as this pandemic is going on in some conversations that I have had with emergency Department
22:49:04 physicians recently they have said they are seeing an increase in the number of assault
22:49:09 related injuries they are seeing in the emergency Department these are often things happening
22:49:14 when people are getting into an argument over something on the street or getting into an argument
22:49:23 over whether or not somebody’s wearing a mask or distancing themselves enough or assaults on workers
22:49:29 who are trying to maintain protection at some place of business and some of those workers have not
22:49:38 been trained in how to deal with workplace violence. We again see this increase in assaults and
22:49:45 the risk of more assaults occurring over time. Next slide. Some of the risk factors for mental
22:49:53 health issues an suicide. The social isolation is a major one. Fear certainly becoming ill or
22:49:59 dying from the virus. The stress that people are under whether it’s stress of job loss, stress
22:50:06 of having their children at home with them and stress of being in a situation where they don’t have
22:50:13 their usual social supports and the economic losses that we talked about earlier. Suicide risk
22:50:25 calls to a suicide hotline in LA increase TPR-D 20 in the month of March in 2019 to 1800 in 2020,
22:50:32 certainly depression is another risk factor and where people who suffer depression and who
22:50:41 May not be able to access their health care provider or mental health care provider it certainly
22:50:49 is a health issue. Health care workers who are exposed to stresses who take care of parents
22:50:56 with COVID 19 prehospital and emergency medical services an physicians an nurses and respiratory
22:51:03 therapists the range of people who are taking care of patients with COVID 19 and are seeing the
22:51:12 death and the outcomes an the difficulty that is people are having with this pandemic. Next slide.
22:51:22 Another issue is with firearms and we know that firearms sales in March increased 85% compared
22:51:28 to March of 2019 an was the highest firearm sale that is were ever recorded in the United States.
22:51:39 We have seen people at state rallies at government centers rallying with firearms saying they want
22:51:46 things to open up. This has been some of the sort of push to open some people have carried guns
22:51:57 open carried and then we know that people who purchase a gun or a handgun have a 22 fold rate of
22:52:03 suicide within the first year than people who don’t have one. In men especially for every ten percent
22:52:10 increase in firearm ownership rate at the state level there’s an increase in suicide of 3.1 of
22:52:16 a hundred thousand people. The presence of a firearm at home is associated with a two to ten times
22:52:23 greater risk for suicide than in a home without a firearm. In addition to that we know that it poses
22:52:31 a risk not just related to suicide but if firearm is not stored properly or safely to children
22:52:38 who might pick up a fair arm that the loaded, so we know that there are a lot of risk far TORs that
22:52:46 are now in place because of what we are seeing with the increase in firearm ownership. Next slide.
22:52:53 So far on violence we also might have thought that we would see significant decreases however, we
22:53:00 have seen decreases in mass shootings and those are the smaller proportion of the shootings that
22:53:08 we see and this year Chicago had it’s deadliest memorial week end since 2015. Ten people were
22:53:17 killed and 39 WOUPBed and fatalities from gun violence increased by 14% this year compared to
22:53:27 the same period than last year. Other cities are seeing other issues similar to Chicago Philadelphia
22:53:33 and Baltimore and a lot of — are concerned once the lock downs are lifted and the weather improved
22:53:37 we are going to see some additional increases in violence.
22:53:45 >> Next slide. One of the otherrer issues is alcohol an other drug use and we know as a baseline
22:53:58 about one in 12 U.S. adults has a substance use disorder. Only about 7% of physicians can
22:54:10 treat opioid addiction who is to help someone who ask addicted to medications. Individuals who smoke,
22:54:18 SRAEUP or use opioids or use meth amphetamines are probably more vulnerable to
22:54:26 the worse outcomes associated with COVID 19 because of their respiratory, the impact on their
22:54:32 respiratory system. A lot of individuals have lost access to their usual support systems. They
22:54:41 are also stressed they maybe unable to get to their group support and kinds of activities that
22:54:48 they normally would and so they have risk factors for relapse an self medication. We know alcohol
22:54:57 beverage sales have increased by 55% in late March and we also have seen cities an states
22:55:05 put in an option for take out food orders with alcohol. We see people have on-line happy hour in
22:55:12 meetings. There’s also now some reports of people who are working from home not finding
22:55:21 it unusual to have a drink as they are working from home. There’s difficulty in connecting with
22:55:26 support groups for many people. For other drugs the social distancing May increase the risk of
22:55:32 over dose, deaths an the physical effects of the drug use can increase the risk of complications
22:55:42 from COVID 19. Next slide. So you know in kind of a summary of what we are dealing with multiple
22:55:48 public health crisis during the pan TKEPL I the violence, mental illness an drug use and alcohol
22:55:54 use these are not going to go away as we open things up. Some of them May get worse. There maybe
22:56:02 people who have some of the risk factors or symptoms of some of these problems who did not have
22:56:09 them before the pandemic. We really need to be thinking about how we are going to consider the risks
22:56:16 for the interpersonal an self directed violence that we are seeing now as I said might increase
22:56:22 some of the mental health issues an the increases in alcohol an other drug use and this also includes
22:56:29 providing people with access to the services and they will need in order to deal with some of these
22:56:36 issues. So we have multiple public health issues to deal with along with the pandemic and
22:56:43 I think these are going to be some major challenges for us.
22:56:55 >> Thanks so much for that as well and you know as I’m listening to you an connecting some thoughts
22:57:04 between your talk and — talk somewhat depressing talk has been a really an increase in the use
22:57:10 of tele health for behavior health and particularly for substance use disorders we are now suddenly
22:57:19 seeing a lot of innovation and far fewer restrictions in prescribing methadone an other things
22:57:24 through tele health so maybe as we get into the Q an A it might be interesting to talk about some
22:57:31 of the positive innovations that have come from this as well. So you all been sending in lots of
22:57:40 great questions and laura thankfully has been sending them to me an I might paraphrase a couple
22:57:55 of these and combine them as we go forward and so maybe the first question I think is going to be
22:57:56 for you craig you know you are sort of no stranger at all to the politics of emergencies an yet
22:58:06 most of the kinds of disasters that I think you have been involved in responding to people are to
22:58:14 a large part able to respond a little bit apolitically. It’s a space where we have seen people across
22:58:55 the political spectrum come together to help one another out in response and some aspect of the recovery.
22:59:00 This pandemic has gotten really politicized in lots of ways. My cochair will tell us that whether
22:59:04 you wear a mask or not in Atlanta is taken as a indication of which political party you belong to
22:59:56 et cetera. I am wondering craig if you have thoughts about sort of opportunities to depoliticize
22:59:56 this as we think about responding to other kinds of emergency’s over the summer and fall
22:59:57 and any advice that you might have about how to accomplish any of that an then if others want to
23:00:05 jump in they should feel free.
23:00:06 >> I don’t know how we address the culture war we are seeing played out it’s a long term war on science.
23:00:06 I think it’s important particularly the health care community speak with clarity not and not tell
23:00:06 people what they need to do but explain to them why they knead to do it. Ultimately the public
23:00:06 is going to have to make their own decisions but I prefer they do it with an informed decision an
23:00:07 know the why hopefully we see compliance. As we go into the potential for hurricanes this will
23:00:07 become a great concern in shelter operations if we see a high degree of noncompliance as a political
23:00:07 statement at the same time we May literally have hundreds if not thousands of people in
23:00:07 care settings in these evacuations and the potential exposure there. I think we do a lot of there’s
23:00:12 a lot of politics here I think we do a lot of telling people what to do. I am not sure they are
23:00:20 sharing the message on why we ask them to do that. That’s going to be our key to help increase
23:00:25 compliance an understand some people no matter what they say won’t be compliant what so ever and
23:00:28 it’s impacts on potential spread.
23:00:35 >> No thanks for that I think that’s an incredibly well taken point and it seems that emergency
23:00:42 planners an public health planners both could be working right now on the kinds of messages for why
23:00:48 you are going to need to take these kinds of actions. Should we need to evacuate and get into shelter
23:00:54 operations an others maybe it’s an opportunity to take away some of the labels I guess
23:01:03 I guess we can see there. I don’t know if anybody else wants to get into this bit of a conversation
23:01:16 I can’t see folks for whatever set of reasons. The next question I think I might start proposing
23:01:24 to our first two speakers, that has to do with the fact that we all know that disasters you know
23:01:34 sort of are an equal opportunity destroyers an that poor an minority populations are just are often
23:01:40 just proportionately impacted by all kinds of disasters whether they are natural disasters or whether
23:01:48 there’s pandemics and we have seen obviously lots of excess mortality marly in African-American communities
23:02:07 during this. I am wondering whether your model is to to look at the equitity conversations
23:02:16 as we think about reopening either I know one of the questions asked about your being an on off
23:02:28 switch. More or less implications for equity an then maybe if you can talk a little bit what we
23:02:37 are seeing in the health care system with the equitity situations. Sure I think this’ a great
23:02:56 question this is reporting out by race by income and those factors are highly correlated with
23:03:09 what we do so we in fact do have that going inside the model but we are not reporting it out separately.
23:03:25 It’s something that we want to do at some point. I think the issue is of course with race is in
23:03:32 the front line or backside less likely to go to a doctor early on maybe because they are afraid of
23:03:40 other pocket expenses even though the law is the law in terms of hospitals and coverage for
23:03:52 COVID related stuff it’s true that if you lack at some of the areas more at the ZIP code level.
23:04:14 This personal social distancing that kicked in some ZIP codes happened a lot faster. Lower concentrated
23:04:20 areas do they trust government and do they trust what they are hearing or do they take personal action
23:04:34 and we saw from evidence that we haven’t required to work out yet. Even before policy. I tend
23:04:40 to see more personal social distancing happening before the policy relative to similarly dense
23:04:51 ZIP codes and with lower income. There’s a lot of nuanceses we don’t get into the normative language
23:04:58 about what the government should or should not do. One reason why it’s hard, numbers are tracked
23:05:07 by both sides. I mean our numbers we reported on Steven coBert and rush limb because think
23:05:15 about both sides of debate here. We appeal to both sides we never say is this right or wrong an
23:05:23 let the chips fall where they May? At the same time we are about nuance there’s a lot of nuances
23:05:33 here and besides the obvious issue is about front line workers an ininsurance status that
23:05:40 has to be addressed. If we show in the slide is that personal social distancing is really important.
23:05:47 Trust in government mess APBLing this also comes very important. If you don’t trust the messages
23:05:53 coming from your government and therefore don’t change your social distancing in response that
23:05:57 will lead to more disease
23:06:13 >> Thank you. I think the questions are really critical one here on the the potential, you eluded
23:06:18 to the fact that one of the silver linings of this pandemic are something that I have been excited
23:06:27 about has been that rise in tele medicine. It’s been a great way to bridge care. Doing a tele medicine
23:06:32 or video visit requires what all of you are using right now in this webinar. You need to have
23:06:40 a computer or high speed internet or smart phone with a wireless plan. Many of the audience is well
23:06:46 aware of the digital divide where we see not surprisingly poorer communities an communities of
23:06:54 color as well as our oldest age groups not having that capacity to do this video visit. So this
23:07:00 weird situation we could have which is the tele medicine has been doing an amazing job at least
23:07:09 partially meeting the access needs of nation but at the same time those very high risk communities
23:07:17 could be actually not able to join in therefore in a strange way tele medicine might be increasing
23:07:24 disparities it raises another thing to focus on for the coming months an years how do we bridge
23:07:29 that digital divide there’s many federal program that is are available. Do they have the resource
23:07:35 that is are necessary because that has become so critically important in terms of people’s
23:07:36 health
23:07:43 >> Thank you. So the next question is also sort of a positive question. Which is how might the health
23:07:50 care an public health systems be permanently changed by COVID 19 and other then tele health what
23:08:03 are some positive innovations? So maybe I will ask you to comment first ATIV and then Linda if you
23:08:07 have thoughts about that too feel free to chime in.
23:08:15 >> It’s a great question you stole my thunder I was going to talk about that. It has been an amazing
23:08:21 aspect I will say the point. The changes that we expected to happen over a decade happened in three
23:08:27 weeks it was a remarkable change. I do think that as we look throughout the health care system
23:08:35 we are starting to see innovations accelerate in and the changes that we are making, so one of the
23:08:40 things that I have been really intrigued about is that because patients are staying at home
23:08:46 we are thinking about how we can provide care in the home an maybe giving patients a little bit
23:08:52 more ownership of their health care problems. To be a little bit more concrete do women need to
23:09:02 come in for those prenatal appointments can’t OBG send them home with fetal heart monitor that
23:09:09 is’ really helpful for a mom who already has a toddler in the house. We are questions how much of
23:09:15 that care needs to happen an can we provide that care within the home. I think that’s an important
23:09:21 aspect of it because the pandemic has challenged some of our usual ways of doing things in a way
23:09:28 that I think we will have a lot of positive benefits as we move forward 678
23:09:35 >> I would say that the question of tele health I think it’s a great opportunity to see some development
23:09:42 that way but I think that some of the issues that are now coming to light because of the pandemic
23:09:49 vulnerable populations is going to be people who can’t access care or don’t have ways to get to
23:09:55 care and don’t even have internet available to them at their home because they don’t you know
23:10:03 the lower income they are not able to afford it. Those are some of the things that I think
23:10:08 we can now start to think about how do we address them an use this opportunity to figure out how
23:10:21 to address some of the vulnerable people in various places live. We see the vulnerabilities of
23:10:29 people who live in food desserts right new they can’t get food because there’s in place to go for
23:10:35 them near by. They can’t get out of their shelter in place they are locked down. I think that
23:10:41 one of the interesting pieces of all of this is we didn’t, we didn’t move to open the library as
23:10:49 quickly yet, there was an advocacy for opening the libraries where a lot of people who don’t have
23:10:57 other kinds of access to internet an to the you know everything can’t it’s where they might go to
23:11:04 do things not that would be, we would have to implement a number of kinds of safety ways to keep
23:11:09 them safe. I think it’s something we need to think about.
23:11:15 >> One other thing I might add for one of the points that was made the use an concerns about substance
23:11:22 use that are 457ening after increasing during the pandemic. On the treat side you eluded to this.
23:11:31 You might emphasize that aspect of that too. The pandemic has led a lot of providers who treat opioid
23:11:38 disorder to think about how they manage it. Do we need to have patients come in every day an when
23:11:46 do patients do we need to do urine tox testing on a certain interval. Those kind of changes
23:11:54 to the care patterns can increase access to care for patients because they will be able to get
23:11:59 that care without having to go in every day. I want to highlight that because that was a negative
23:12:06 we raise which is a concern about substance abuse it’s a positive effect of potentially changes the
23:12:13 way we provide care by providing care for substance abuse disorders.
23:12:19 >> I think going along with that too if we are making sure that more primary care physicians are
23:12:28 able to you know prescribe — people aren’t going to a methadone clinic in order to deal with an
23:12:34 opioid addiction or something that would make a big difference as well because you take away some
23:12:35 of the stigma that people might have.
23:12:44 >> Thanks, so the next question is one I know I think I have heard a lot over the years which is again
23:12:50 for craig which is can you comment on opportunities for state an local health Department’s to better
23:12:58 collaborate with state and federal emergency management? I might maybe put an additional twist on
23:13:05 this question which is sort of what do you, how do you think that we can leverage what’s happened
23:13:13 in this pandemic to actually improve the collaboration and coordination? You know what are the
23:13:26 positive changes that have occurred and how can we accelerate and make them last? I think when you
23:13:33 are talking about a pandemic at least when we were planning for it we saw this as a team effort
23:13:40 public health will be primarily focused on the epidemiological an the protective measures in dealing
23:13:46 with the the disease directly an emergency management would support that in plan for the consequences
23:13:55 of the impactses of the disease. We did a lot of this with H 1 N 1 looking at how various industries
23:14:02 would be impacted not so much by social distancing but the impact of people being sick an unable
23:14:09 to work. So I think those lessons we somehow got away from an we need to reenforce that a pandemic
23:14:17 is not just a public health energy it is a disaster. And we need all of the various components
23:14:26 working together and complimenting each other and allowing public health to be the lead on the disease
23:14:33 an using emergency management in those teams to support that process but be prepared to deal with
23:14:40 the consequences and the fact that disasters don’t stop for a disease out break or virus
23:14:46 and constantly updating that planning process. It only works if the organizations trust each other
23:14:53 or work as a team and are less concerns about who is at the podium speak next to the President an
23:14:59 more about how do we ensure that we work as a team for the well being of our communities?
23:15:06 >> Well said and I can think of so much of the pandemic planning we did both during H 1 N 1 incorporating
23:15:13 lessons learned an doing it again duringer bole La situation. Et cetera. I think you are right
23:15:19 there are just so many opportunities for team work to continue to improve planning. Also to use
23:15:38 the plans that we have. So next question is I think goes to professor SMITTERA and maybe to AFITUS
23:15:57 or Linda with question is are we seeing the same kinds of trends — Inaudible. — mental he’ll
23:16:09 an violence. Let’s start with professor SMET T*RBGER, I only heard part of the question I think?
23:16:11 >> I think you froze for a moment.
23:16:17 >> The question really had to do whether we are seeing the same kinds of things internationally that
23:16:25 we are seeing here in the U.S. whether it’s on impacts on the economy and economic recovery which
23:16:30 might be particularly interesting since other countries chose to handle their own employment situation
23:16:37 differently than the U.S. Whether we are seeing it similar changes internationally in use
23:16:43 of the delivery system an decreases an maybe from the mental health and domestic violence perspective
23:16:44 as well.
23:16:52 >> Right from the economic perspective and transmission perspective there’s a lot of heterogeneity
23:17:00 throughout the world I mean of course it’s coming back to the earlier point that was made if countries
23:17:06 are prepared for this like in Taiwan they are very prepared ahead of time for this that is going
23:17:18 to mean much fewer cases an infections and in their case they only had 8 deaths so far an also much
23:17:25 less shutting down of the economy, so we have seen lots of heterogeneity in terms of south Korea
23:17:31 and Japan how they locked down was very different than say the United States there was actually
23:17:36 not as much locking down but the same time they had more testing and as well as more contact tracing.
23:17:44 I think contact tracing despite the buzz around it it’s not very effective when you don’t have
23:17:53 rapid tests and at least that’s what the models an the data seems to be suggestioning. The opposite
23:18:00 is SWEDEN where they didn’t shut down very much at the same time you know they have had in terms
23:18:07 of cases per hundred thousand actually despite a lot of media comparing SWEDEN to Finland
23:18:15 and Denmark, SWEDEN also has fewer cases than other countries that went on lock down including
23:18:23 the United Kingdom an others. There’s tremendous heterogeneity. I think one of the common factors
23:18:29 does come down to personal social distancing. In SWEDEN they could get away from
23:18:36 it. There’s a communal factor there it’s a much more homogenous population. Trust in government
23:18:44 is high. People like the pay their taxes there and because of that trust and people took on personal
23:18:51 actions. Did they see their economy slow dun they did simply because of personal social distancing
23:18:57 meant that despite what you saw on TV where restaurants being full. Restaurants were less full
23:19:05 than they usually were and so a lot of the slow down is not just legal it’s also personal social
23:19:12 distancing. I think for the United States it’s really hard to gleam what is the right lessons
23:19:21 because if we for example as we remove lock downs and this is going to be Hong Kong or are people
23:19:27 took it as a signal that things are okay and so they really reduced their personal social distancing
23:19:33 or is it going to be a little bit more like scanned knave KWRAPB countries where people understand
23:19:39 they have to be very careful here. I think that’s going to be vary allot across states in the United
23:19:46 States. I don’t think the United States is a homogenous population like other countries I think
23:19:53 it’s going to be a heterogeneous reaction to it and it’s going to be state by state and county
23:19:55 by county response.
23:19:58 >> Thanks.
23:20:05 >> Have you been tracking the health care utilization in other countries and have similar things
23:20:14 >> I haven’t been tracking but I can tell you drops in visits was echoed in other countries. As
23:20:22 well as tremendous investments in Intel an medicine. I think one of your question was related to
23:20:28 mental illness. I the think there is a divide there that I am concerned about building on this divide
23:20:34 I talked about here in the United States and the digital divide. Majority of the visits I have
23:20:39 seen in the data health care side are divided by tele medicine right now in the United States.
23:20:45 That means that’s been the we that those visits have been provided an that’s why the number of visits
23:20:51 has declined relatively less than in other clinical areas that is not the same opportunity
23:20:57 as it is in other nations so that’s going to be a major issue in that particular area in other countries
23:21:03 where they May not have that ability to quickly transition to the tele health side.
23:21:07 >> Thanks. Did you want to comment on this Linda?
23:21:13 >> Sure I think I would agree with that it AO ES a issue of transitioning to the tele medicine. I
23:21:19 think the other thing we need to keep in mind is what might go on in a developing country where
23:21:27 there isn’t so much access to care to begin with. So we have a you know and then you have places
23:21:34 where you have refugee camps an we have other group you know other large sort of settlements of
23:21:41 people who don’t have access to health care or very much access at all on a regular bases, so I think
23:21:50 we will see a lot of differences there that we wouldn’t see looking at Europe or you know UK, Hong
23:21:55 Kong and those kinds of places. I think we need to keep that in mind as well.
23:22:01 >> Good thanks. Let AOE do one more question I think then I can try to share a couple of thoughts
23:22:13 and see this one is really about how much of the perceived avoidance in nonCOVID care is due to
23:22:20 fear and how much is due to health care facilities stopping elective surgeries et cetera. The
23:22:26 next part of the question is how can we pursuade the public that’s not only safe but imperative
23:22:27 they seek care?
23:22:34 >> Yeah that’s a, you know one of the themes across all the presentations has been the challenges
23:22:40 an communication that we have. And so I think that in many ways we are very successful as a health
23:22:47 care world saying look stay home when you need to but in doing so there might have been over that
23:22:55 message May not have the nuance or clarity necessary that, if there’s something significant in major
23:23:03 that we want you to come in and so I think that message and the rebound that I described to you
23:23:09 is the fact that we are doing a bit of a better job. If you have a health care problem it is safe
23:23:14 to come into a clinic. There’s numerous precaution that is have been made both in hospitals
23:23:21 as well as clinics to decrease transmission. I think that’s going to play a role with the tele medicine
23:23:28 side. It’s a nuance story. We want the say look it’s safe you can come into our clinics an get
23:23:36 care but you know if you don’t have to come in tele medicine is a little bit more safe. That’s
23:23:41 another nuance that’s going to be a difficult thing for us to tell. Again, it’s a challenge in communication
23:23:48 that we are going to see there from hurricanes and whether you need to evacuate to whether you went
23:23:54 opening up the economy is what does that really translate into your personal behavior. So
23:23:59 a very public health message that is always there in terms of public health communications.
23:24:09 >> Let me see if any of our panelists want to have a last word before before I sum up? Okay. So
23:24:15 you know I will just maybe a couple reflections as I have been listening to these terrific presentations
23:24:22 an really interesting questions an I just want to thank the folks on-line for really terrific an
23:24:29 interesting questions that always makes things much better I wish there were a way to make this
23:24:36 a little more interact T*EU. As I was listening to this I was thinking about my experience over
23:24:44 the last month serving on the steering committee for the DC mayor in terms of thinking about reopening
23:24:53 and you know I know professor SMETTERS we use your work in others in thinking about that. It’s
23:25:00 a very interesting experience to think about how it is that you might balance projected health impacts
23:25:07 particularly increases in transmission and as imperfectly modeled as they might be from different
23:25:15 phases or stages of reopening an different kinds of behavior how it is you as a city or state
23:25:28 how to balance that with jobs and with tax revenue for the city. To do it all really through this
23:25:35 lines of equity. I think the presentation for today really sort of highlighted some of the nuances
23:25:46 of some of the challenges that we face by making those recommendations. The other thing
23:25:53 we are challenged with is how is it we might make some of the changes that might have been more
23:25:58 positive perm TPHEPD in the process. Some interesting conversations really came out of
23:26:08 that. You know one was to think about a really huge push to expand internet access, to poor income
23:26:18 areas or have subsidized or free wifi recognize ing from an equity perspective it’s a prerequisite
23:26:26 to sign up for benefits. We have tons more people who are uninsured an recognizing that as a
23:26:32 prerequisite for being access or being able to access tele medicine and tele health Frankly recognizing
23:26:43 that it’s really essential for, recognizing for as long as schools there might be closed or on
23:26:50 modified schedules this’ really essential to learning that’s an example of a really big kind of
23:26:58 push that came out of it. You know a second example of a set of pushes that came out of it was really
23:27:06 thinking about how to strengthen an amplify an potentially change the kinds of people who might
23:27:11 be working in health Department’s or working with health Department’s thinking about contact tracing
23:27:21 an how to mobilize community violence prevention specialists, HIV educators and others to think
23:27:31 about them being trusted community leaders and really working together with or learning to do
23:27:36 contract tracing in communities buzz they May be the ones that know the community the best. Talking
23:27:42 about violence prevention through social distancing an AMBASSADORS and particularly in area that
23:27:51 is are hot spots of transmission. So there was actually a lot of opportunity I thought for innovation
23:28:01 just coming out of the experience that very much I think reflected some of the con conversations
23:28:17 that we have had today. I think another thing that hads come out of this but despite the the political
23:28:27 divides an how politicized this has been people in other disasters being nice to each other and
23:28:34 special efforts to help seniors who are stuck at home think about how it is to get your grocery
23:28:40 shopping done an doing all of those sorts of things. I don’t know if we can make them stick maybe
23:28:48 we can? Similarly in the health care system the whole crisis in PPE has made us think about how
23:28:54 it is that we used health care resources an how to take steps to avoid crises standards of care.
23:29:02 How is that we reuse an substitute and recycle and think about how we use resources so that we don’t
23:29:08 get into a crises. Those are kinds of things that we could do every day to help our health care
23:29:17 system be more efficient. Another question or comment on really the unprecedented level of scientific
23:29:24 collaboration we have had in some areas whether it’s around diagnostics development or understand
23:29:30 the epidemiology or vaccine development or scientific collaboration from around the world how do
23:29:37 we bottle that and think about making it last. Finally, I think when ever we are faced with any
23:29:44 kind of major crises like this we really think about well is the goal here to rebuild back to where
23:29:52 we were or is the goal here to rebuild back something better? And to think about areas in great
23:29:58 need of redesign. I think we have touched on that a little bit today in terms of thinking about
23:30:06 aspects of the health care system. I think from professor SMETTERS talk there’s a way to think
23:30:12 about how it is we redesign some aspects of our social safety Neto think about how to become more
23:30:20 resilient to different kinds of disasters whether it’s how we think about how to subsidize unemployment
23:30:25 or what it is that we are going to do to help people maintain health insurance or how we are going
23:30:33 to continue to strengthen our public content infrastructure going forward. Those are all challenges
23:30:44 for us ahead. As we think about our summer of COVID. While you are social distancing at the beach
23:30:51 or other things thinking about how to rebuild positively and make positive aspects of things last
23:31:00 a really just so important. Let me close by reminding you that our next webinar is June 10th at
23:31:07 5:00 o’clock. It’s call it had road to immunity to COVID 19. It’s really about developing an
23:31:13 distributing the vaccine. We will see where we are by then in that adventure as well. Thank you
23:31:21 all again for participating and our panelists for terrific presentations an our staff for whom this
23:31:27 would be just absolutely impossible to do for those of you who are interested this webinar has been
23:31:34 recorded and our recording a transcript will be available as well the slide presentations so there’s
23:31:39 been a lot of interest I think in getting access to the model and so I expect that there will be
23:31:47 a lot of demand for that. Thanks again for joining. Please stay safe, stay healthy and until next
23:31:48 time bye bye.

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