PIPER

Hello, and welcome to another episode of “Inform Me, Informatics.” I’m sure we’ve all gotten a million emails lately peppered with phrases like, “In these uncertain times,” and, “We hope you’re staying safe,” but before getting into the show, I just wanted to say, with all sincerity, I hope you, the person listening to this episode, are holding up OK physically and mentally. Since our last episode, the crisis in the U.S. has reached new heights. This past week, which was the closing week of May 2020, the COVID-19 death toll in the United States surpassed 100,000, representing almost a third of all worldwide deaths from the pandemic. And the infection count of known cases in the U.S. reached 1.6 million.

I’ve been trying to better wrap my head around the enormity of the situation and what public health is up against here, and in the spirit of that search, I reached out to one of the leading expert voices of the pandemic, Dr. Carlos del Rio. Dr. del Rio is an infectious disease specialist, a professor of medicine, global health and epidemiology at Emory University and the executive associate dean for Emory School of Medicine at Grady Health System here in Atlanta. In his role as dean of Emory at Grady, Dr. del Rio is in the thick of the fight against COVID-19 every day. As the pandemic has worsened, he’s also taken on the informal role of health educator to push back against the ongoing flood of misinformation. He’s begun communicating with the public through these Q&A sessions that Emory University is live streaming over Facebook. The sessions top at times 100,000 views, and they answer viewer-submitted questions like, “Should I get the antibody test?” and, “Is it safe for me to go to my neighborhood pool?” He responds to questions and concerns with clarity and empathy and has over the last couple of months become one of the most recognizable experts speaking on the pandemic.

Even with his hectic schedule as a healthcare and academic leader, Dr. del Rio very generously agreed to come on the show and share some of his perspectives on the pandemic. From the data crisis to the ways that the virus has spread has deepened existing health equity gaps. I started our conversation by asking him the question I find myself wanting to ask everyone right now, especially those on the front lines.

PIPER

First of all, are you OK?

CARLOS

Yeah, you know, I’m fine. I think that we’re all having a little bit of, I would say, PTSD, you know. I think that it’s really very challenging. It’s really a combination of excitement in those of us in infectious disease and epidemiology and public health always…you know, this is our time. But at the same time is very sad and very sobering when you realize how many people have died, how many people have been impacted. And it’s not just the pandemic. Also, I think the economic consequences, the depression that has occurred, the 30 million people that have lost their employment, the economic downturn. So, I think it’s also a very sad time and a time to really, you know, really reflect and think about how quickly the world has changed on us, right, how quickly we went from one world to another.

PIPER

Yeah, absolutely. It’s been a very quick and sort of jarring transition. I wanted to ask you a little bit about your experiences right now and what is this fight against COVID-19 looking like from your perspective at Emory and what are the top priorities and challenges that you’re personally seeing right now in your own work?

CARLOS

Well, I think, you know, it’s a combination. I think at the beginning it was almost, like, when the storm hit, all of a sudden, we realized this was gonna be bad, that we’re gonna have a lot of cases. So, in my job down here at Grady Hospital as, you know, the Emory dean down here, it was really working with the hospital and with the hospital leadership and ensuring that we were gonna be able to cope with this, right? And it was all the way from, you know, getting us personal protective equipment to ensuring that we had everything that was gonna be needed to take care of the patients. So, my number one priority was to be able to take care of patients. And my number two priority was making sure that our healthcare workers were protected. That kept me up at night, right? I didn’t wanna see us go through the same way that New York went through. You know, I was talking to colleagues in New York who were saying, “We have over 150 patients who need ventilators, and we only have beds for 75 of them. We’re overwhelmed. Our ICU capacity’s exceeded.” I didn’t wanna get there. And I also did not want to see, you know, our healthcare workers infected and dying as a result. So that was, again…my initial work was really trying to do those two things. And it was incredibly challenging because…just to give you an idea, you know, today on a typical day now with COVID, the hospital is using about 2,000 masks, about 4,000 isolation gowns, about 120,000 pairs of gloves, which means that the daily cost of personal protective equipment for healthcare workers here at Grady is about $66,000. People don’t realize that. You know, we didn’t spend $66,000 a month in personal protective equipment. Now, we spend that amount in a day.

PIPER

Wow. That is incredible to think about. So, I wanted to ask you what kind of data challenges would you say that the public health response against COVID-19 is experiencing right now and what would you say the problems are that result in a pandemic from a lack of timely data?

CARLOS

Well, I mean, I think there are several things there. First, so one of my roles here in the hospital was…my other role was actually speaking to leadership in the city, and, you know, I have the opportunity to go speak to something called the ACP, the Atlanta Committee for Progress. And that’s a group that includes some of the major leaders. You know, Dr. Sterk, president of Emory is there, the president of Georgia Tech, the CEO of Delta, the CEO of Home Depot, of, you know, our major companies but also the mayor of Atlanta was there. This is way before we had anything here. This was, like, early March. And I said, “Look, guys, this is gonna hit us like a rock. We gotta do something. We gotta move.” And the mayor was really very open, and we continued talking, and I talked to her, and through her, I could talk to all the mayors in the state. And I then, you know, talked to the governor’s office, and I really was trying to, again…to help us, you know, close down as quickly as possible so we can start to flatten the curve, right? We can prevent a flood of patients coming to hospitals and decrease in mortality and really trying to get that policy decision.

So, it happened, but as, you know, we were one of those last states to close, and we were one of the first states to open. So, now, I think, you know, we achieved some of our initial responses. Now, I think the issue is how do we continue minimizing the impact of the epidemic in our city and in our state and in our nation, and, quite frankly, you know, what do we need to do that? And the things we need is, number one, we need data. And data is really, really very important. And I would say that without data and without reliable data it’s very hard to make decisions.

But this is the first pandemic we have at a time of social media, right? And so I also quickly realized social media had to be used, and I had to get on…I was already a Twitter user, but I would say, you know, when the pandemic started, I had about, I don’t know, 6,000 followers. And I started to tweet around the pandemic because I realized that this was critical, that we had to get information out there because the information that was coming out, was dominating is misinformation, and I just worried, without the necessary information, we were not gonna be able to respond appropriately to the pandemic. So, data and information are so critical, but there are other sites where you can get good data, and I think it’s also been fascinating to see the proliferation of good websites where data is available and where you can get the necessary data.

PIPER

Do you think that we’re currently worrying about any of the problems resulting from a lack of timely data and what do you think those are?

CARLOS

Again, you know, the data has never been timely for no disease. So, I think part of the problem is we have…is that we’re flying blindly, right? And I think the systems that surveillance has for timely data need to be updated, and I think this is an opportunity to really do with data what we’ve never done before, which is actually take it seriously and do it the right way, right?

PIPER

That definitely makes sense. Yeah. So how would better data capture and information help in the fight against the pandemic? And what’s kind of on your COVID-19 data wish list?

CARLOS

Well, I would like to see immediate information. There’s a website called atlstrong.org, which is the website we put together with the mayor’s office, and there there’s dashboards, and if you look at one of the dashboards there is the kind of information that I think you need to have in order to fight this epidemic. You need to know how many people are coming to your emergency room with influenza-like illness, your hospitalizations for COVID. You need to know what percentage of people have positive test. You need to know what’s your critical care capacity, what’s your bed availability, how many tests are you doing not only in the state or in the city but actually down to the county level. So, it’s really all this nuisance that need to come, and data has to be quick, has to be immediate, has to be acted upon. I think, for example…let’s say when a patient is diagnosed in a clinic or in a testing site or in a hospital, we need to get that information immediately to the proper health authority so we can do the contact tracing because contact tracing of the disease has to be done quickly. You cannot do it the old fashion way. It was, you know, slow contact tracing. If you do it slow, then by the time you get to it, everybody’s infected, right? And we’re seeing a lot of transmissions happening in households.

And I think that’s the other thing that I think the pandemic has done is, you know…there have always been racial disparities and ethnic disparities and, quite frankly, socioeconomic disparities in outcomes in this country, and they’re growing day by day as economic disparities are growing. And, you know, just think about the life expectancy, you know, between people living in Buckhead and the people living in Bankhead. It’s almost a 10-year life expectancy difference, and they live in the same city, you know, in the same county, but they live in different ZIP codes, and one is a rich ZIP code, and one is a poor ZIP code.

So, what the epidemic has also done is that it has uncovered a lot more of those disparities, and we’re seeing how much more minorities, African Americans, Hispanics are being impacted by this epidemic, and they’re being impacted for several reasons, but number one is, you know, sheltering in place and social distancing is a privilege, right? So, I was treating a patient yesterday, a woman, Hispanic woman, who lives in an apartment with her cousins, and, you know, you have in a two-bedroom apartment seven people living there. You know, if she’s infected, everybody’s gonna get infected. You know, the shelter in place…when you have to go to work because she couldn’t miss her job, you know. Again, teleworking is something that, again, is a privilege, you know. If you’re a lawyer or you’re…many people, you can telework, but if you’re a frontline employee, if you’re, you know, somebody working at a restaurant or, you know, cleaning here in the hospital or in the university, you have to go to work. You cannot telework and be in the cleaning crowd, right?

And so I think poor people because of their jobs, because of their living conditions and because they have more chronic illnesses not only are more heavily impacted but they are more likely to die as a consequence of a disease. So [inaudible 00:12:02] disparities that we’re seeing in this disease to me are really concerning. And I really worry that a lot of our response is being colored by that, that people that were dying were poor and mostly African American and Hispanics. I think, you know, we lost attention, right? We…it didn’t become…all of a sudden, it stopped being a national priority, and that to me is incredibly sad.

PIPER

Thank you for that point. That’s a really good point about the health equity disparities right now.

CARLOS

They’ve always existed except that now they’re more visible than ever, right? I mean, they are so in your face. And we’re just not doing anything about them. We’re not approaching it the right way, you know. We’re not really addressing it the way it should be. The public health response is not just testing and contact tracing and getting a vaccine and getting medical interventions and drugs. The end of this disease is really addressing the health disparities and the economic disparities that exist in this country.

PIPER

That so true. Yeah. Thank you for that point. So, a lot of other countries have dealt with the pandemic in different ways, and we’ve seen it play out so differently in different nations. And I was wondering what do you think the U.S. can really learn from other countries that have approached the pandemic differently than we have?

CARLOS

The first thing we can learn is that having access to healthcare is important, right? So, I think, again…once again, why do we have differential access to healthcare? Why do we not have universal access to healthcare? When I’m hearing somebody say to me yesterday, you know, “I don’t wanna be tested because I don’t have money to pay for the test.” And I had to tell this person, “Well, if you go to get tested at actually this testing site, you can actually get it for free.” And people are concerned that when we have a vaccine, is insurance gonna cover it, is the government gonna cover it, how are we gonna get vaccinated. So, I think we have a lot to learn from just having access to healthcare as a right and something that everybody has access to. Number two, I think we learned from many countries about the importance of testing, right? And we were very, very late to the testing game. We’re doing better now. We’re doing much better now testing much more than we were in the past, but it took us a long time to ramp up our testing capabilities. It took us a really long time to get to where we are right now. We’re now doing close to 50,000 tests per million population. But, man, it took us a long time to get there, right?

And the other thing I would say…and, again, I don’t think this is gonna change, but I think the other thing we learned from many countries is that in most countries public health and responding to public health emergency can be done at a national level. In the U.S., we have a federation of 50 states. Each state is a little different. Each state does their own thing. There’s not a national response.

PIPER

That does seem like it would hamstring things a little bit.

CARLOS

Oh, it makes it not hamstring. It makes it insane.

PIPER

Yeah.

CARLOS

We have one state doing one thing and one state doing another. You can’t really have a national response.

PIPER

So, thinking about what’s going on right now, what is one thing you’d like the general public to better understand about this pandemic? And what’s one thing you would like the public health workforce to better understand?

CARLOS

So, the first thing is that the individual responsibility and what the individuals do really matters in this epidemic. I mean, when people say to me, “Well, you know, have cases gone up because of the governor opening the state?” I said, “Look, you know, the governor could’ve opened the state, but nobody came to my door and said you need to go bowling or you need to go here or there, right?” You have to make decisions, and what we learned is that people did not go to many things and actually stayed sheltered in place till…for a long time. And I think that’s why we haven’t seen such an increase of cases. Now, that has changed lately in the last week, and we started seeing people saying, “Oh, this is over.” And I think the first thing I want people to know is this is not over. Just because, you know, we’re opening the state, the virus has not been notified. This virus is still around. We’re still seeing people get sick. But it’s up to you. You know, you have the power to make a difference. You have the power to protect yourself. You have the power to protect your loved ones. You have the power to wear a mask. You have the power to do safe distancing and physical distancing. You have the power to wash your hands. You can do a lot to not get infected. And I think that’s all in your hands. So, you’re not powerless in front of this epidemic. You can actually do things that will prevent you from getting infected. The number two is that one thing that I’ve learned in this epidemic is how, again…reinforces how giving and how caring many people in this country are, how we’ve seen an outpouring of support for healthcare workers and for all sorts of different things, people helping others, donating, you know, giving food. It’s just amazing to see the outpour of how people are generous. And I think we need to continue being generous. We need to continue helping others. We need to continue working with our community because we need to lose our individualism and highlight our community and how will we work together for a better community as we end this epidemic.

And I think the third thing is that we need to make those in public health realize that this is our time. This is when public health matters. This is when you actually say, you know, “This is me. I’m in this team, and I’m part of the solution, and I’m gonna be active and being part of the solution.” Those in public health, we have to be activists. We have to speak up. We have to be bold. We have to be courageous. We cannot stay quiet because we can make a difference. And we need to continue communicating, and we need to continue generating the necessary trust in science to end this epidemic and not in misinformation.

PIPER

So, what lessons do you think public health can take away from this pandemic? If you could go back in time 5 or 10 years, what advice would you give the public health workforce to protect against the coming pandemic?

CARLOS

Well, you know, the first thing is…so I think about it a lot because I’ve been involved in this for a while, and, in fact, in GH500, I always, you know, taught the pandemic class. So, I go back and think about my pandemic class and what I said there and what I didn’t say there. And, again, if you go to my pandemic classes, it feels like deja vu. It’s like we’re living this over and over and again. And I think there’s several things. Number one is we thought we were prepared and we really weren’t. In other words, we were grossly unprepared. So, I think one thing is that, when this is over, we need to sit down and say, “Hey, we thought we were prepared, we had pandemic plans, and what problems were there?” Well, I’ll give you an example, you know, the influenza pandemic plans did not include the need for N95 masks. So, there were not enough N95 masks. They didn’t even exist in the national stockpile because it wasn’t part of the pandemic plan. So, obviously, somebody didn’t think about it, and I guess all of us didn’t think about it, and I think a lesson is to go back and say, “Gee, how can we improve our pandemic preparedness plans? What are the lessons there from this pandemic that will help us make better planning for the future?” Number two, I think it really emphasizes the need for global collaboration in preparation. When I started hearing there’s cases in early January in Wuhan, China…first of all, I didn’t even know where Wuhan was. I had to look it up on a map.

PIPER

Yeah. I think none of us did.

CARLOS

And, you know, it’s a huge city with 11 million people. Seventh largest city in China. And so I think what happened in Wuhan should’ve mattered to us right away. And I would tell you, I was one of the ones that followed the epidemic in Wuhan on a daily basis. My wife used to joke saying, you know, every day I would look at the data and look at the Hopkins site and see the number of cases, but, honestly, I thought the Chinese were gonna control it. I thought it was not gonna get out of Wuhan. I thought it was gonna be, you know, something restricted there. And I think we should’ve gone into high alert then, not in March. We should’ve started working then and not…and say, “Gee, this is gonna hit us like a rock.” So, I think being better prepared…I mean, the U.S. started really ramping up their testing once the disease was here. We should’ve been ready to test way before. Like, in January, we should’ve started developing tests and being ready to test people then and start testing people then. So, we let the cases come in before we did anything. So, we didn’t really do the right thing to stop this from the beginning.

And number three is that we need to really think about the importance of better funding public health and realizing that our best defense against the pandemic is a strong public health infrastructure. And for years in our country, we have led the public health infrastructure be weakened, be defunded and be relegated to second class. And I think, as a result of that, we’re paying the consequences. And, you know, Dr. Feige used a phrase that I love, and, you know, he quotes Dolly Parton and says, you know, “You have no idea how expensive it is to look this cheap.” We were very cheap in public health and see how much it’s costing us right now.

PIPER

What a great application of a Dolly Parton quote. I love it.

PIPER

At this point in the conversation, Dr. del Rio took a moment to share some words of wisdom about looking to the future and how we can all collectively try to get through this time together.

CARLOS

This is a really tough time, and this is a very uncertain time, and, first of all, we’re here for the long run. Second, people are burnt out. People are depressed. The future’s uncertain. Our economic condition is uncertain. Our mental health is very important, and we need to be sure that we take care of the mental health conditions because COVID is not…should not be the end. Humans, we are very resilient. We have gone over horrible things in the past. I mean, I was thinking the other day about the siege of Leningrad and how, you know, over close to 1,000 days people in Leningrad were bombed and there was, you know, death and destruction. Close to 3 million people day. But if you think about Leningrad today, it’s a beautiful city, has one of the most beautiful museums in the world. So, again, we’ll get over it. We will survive this, but it’s not immediate. And I think we need to realize that resilience and leadership plus science is gonna get us over this. And I think the science today is better than it’s ever been. You know, the time it took from isolating the virus to having the first vaccine enter a human body was 65 days. That has never happened before. So, science is taking us at the speed of light in developing therapeutics and vaccines for this disease. But, again, it’s gonna take time. It’s not gonna be immediate. And I think in this day and age of immediate gratification, we want the vaccine today, right? And it’s not gonna happen today. It may not happen in a year or in two years, but still even two years will be faster than any vaccine that ever has hit the market.

So, we have to have confidence, and we have to be supportive of science to get us out of this mess. And in that sense, we have to be supportive of data. So, data and science are gonna be critical in getting us out of this. And those of us in public health need to remind people of that over and over and over.

PIPER

And finally, we’ll close out the show with a question I ask all our guests. What is your personal definition of public health informatics?

CARLOS

When I think about public health informatics, I think about all that data that we’re generating, whether it’s from public health, whether it’s from our cellphones, whether it’s from all the data…I mean, we have giga billions of data and how that data is then being integrated and applied to making public health decisions because I think, you know, we have a lot of data that we’re not using appropriately. And I think public health informatics is that science of taking that data and applying it to make informed public health decisions and public health intervention.

PIPER

Many, many thanks to Dr. Carlos del Rio for being willing to come on the show when his time is more in demand than ever right now. It was so valuable to speak to an expert who’s operating on the front lines, especially one who has such a powerful way with words and an instinct for succinctly breaking down complex concepts.

This podcast is a project of the Public Health Informatics Institute, which is a program of the Taskforce for Global Health. Visit phii.org to learn more about all of our informatics work. You can also find us on Facebook and follow us on Twitter @phinformatics. Also, one note in the spirit of full disclosure. Since this episode focuses so much on Emory University, the Taskforce for Global Health is an affiliate of Emory University, and like all Taskforce staff, I am technically an employee of Emory University. The music used in this episode, as always, was composed by Kevin MacLeod. If you know of an innovative or interesting public health informatics project or story that you think would be a good fit for the show, let us know on PHII social media or email us at podcast@phii.org. Keep fighting the good fight and stay healthy out there, informatics fanatics. I am Piper Hale, and you’ve been informed.

BUTTON

PIPER

I’m recording this from a closet in my house, so there are clothes hanging in my face right now.