Accountability and Phase II Response to the COVID-19 Pandemic

John Brown, MD and Anu Ramachandran, MD

Our response as physicians and public health providers to the first phase of this pandemic presented a terrifying challenge to modern society

and American medicine. As our community journeys into the next phase, we are struck by the parallels between our pandemic “disaster response” and our daily “routine” needs to prevent further disease and care for our patients. This article proposes a simple premise for success in meeting these challenges - increased awareness of and attention to accountability. I am accountable to you and you are accountable to me.

As we write this in August 2020, we have navigated the initial response as a community in San Francisco and Marin Counties with enviable success - the lowest rates of COVID-19 infection and mortality of any urban area in the United States. This has been facilitated by a combination of Public Health experience and effort exemplified by the work of our Health Officers–Tomas Aragon, Matt Willis, and their respective Departments of Public Health. The community leadership mobilized rapidly into the Incident Command System structure and enlisted the necessary cooperation of all levels of local government. The partnership of health departments, local mayors and elected representatives spanning many Bay Area Counties removed jurisdictional barriers and helped our multi-county mobile population adopt similar preventive measures simultaneously. Most importantly, the cooperation of the public throughout the region has been the crucial element in this success story. Our collective accountability has shaped the narrative of the Bay Area COVID response, and has allowed us the benefit of time for data collection and resource allocation, a luxury denied to many other areas of the country.

Unfortunately, our persistent problems of unequal access to health care, institutionalized racism, economic hardship (worsened by the temporary suspension of crucial economic activity during this period), and our human-nature resistance to change despite evidence of its benefit have continued. While many successful programs and processes exist to address some of these more structural resource deficiencies (such as sobering centers, medical respite shelters, community based recovery and skills training centers) the needs of these programs have increased at a time of diminished government resources. While

some programs were temporarily decreased in order to permit pandemic specific health and welfare processes to be developed, these disparities now must be addressed even more stringently in order to prevent a catastrophic resurgence of the virus. This will not be easy in light of the resources required in a time of economic hardship. To mitigate the spread of virus, we ask everyone to wear a face covering, maintain social distancing in public places and comply with testing recommendations and other public health orders. It is also necessary, as Dr. Fauci from the CDC recently put it in a commencement address for the College of the Holy Cross, for us to “care selflessly about one another”. An open mindedness and sense of inquiry is necessary to look at the results of our social and professional actions, not only our intent. This is one of the pillars of the scientific method—to be honest and transparent, moreover to be prepared to change our initial or usual approach if it is not working. The challenge of infectious diseases to emergency physicians is the longer time scale for the diagnosis and treatment, the patience required in gathering necessary data, and the stunning difference a small change makes in mitigating the number of sick patients entering the emergency care system. Focused attention and perseverance are key. All physicians need to be accountable to our patients, as do the professionals we have the privilege of working with—nurses, specialty care technicians, medical assistants, EMS providers, administrators and insurers. We must be sure to provide the best possible care we can and to protect our health every day in the workplace and at home. Part of this accountability on our behalf is an acknowledgement that this disease is causing disproportionate harm to our Black and Latinx patients, a tangible reminder of the inequities that persist within our healthcare system. We must take lessons from the nationwide conversations about social justice and make daily efforts to better ourselves, our colleagues, and the systems we work within to serve the communities most affected by this disease. Patients need to be accountable to each other and their families, friends and providers by adhering to effective directions and guidelines and taking charge of their health as much as possible in order to not overwhelm the healthcare system.

Public employees need to be accountable to the public they serve, from small measures, such as providing safe options for public events/services from voting to riding transit, to larger, more difficult measures such as modifying treatment protocols and changing de-escalation strategies to increase safety and prevent harm. They will all count. Politicians need to be accountable to their constituents who are unable to speak for themselves through increased awareness of and support for public health actions/non-pharmaceutical measures to control the pandemic. Political leaders can tackle the status quo and challenge privilege and powerful economic forces responsible for societal stress and emotional confrontation. Assertive and thoughtful actions to change negative behaviors and redistribute resources are difficult but necessary in the era of this pandemic.

Business owners and leaders need to be accountable to their employees for their safety and economic well-being. The most important element of a thriving economy is the people that facilitate economic growth. The more death and disability we allow by our actions and inactions, the more damage our economy suffers in the long run. The media can be accountable to the public by verifying new developments in the science around this disease, dispelling rumors and challenging the accuracy of stories amplified by social media that make right action hard to discern.

Professional societies such as the SFMSS need to be accountable to their members and to the patients they serve by focusing on changes in current medical practice on all of these fronts— pandemic countermeasures, anti-racist practices and programs, overcoming disparities and difficult access to care. The track record of our society in so many of these arenas has been excellent, from advocacy on increasing health coverage to speaking truth to power on health issues from smoking to healthy eating to addressing behavioral health and gender/race/age related barriers to care. We have partnered with the San Francisco Department of Public Health in these efforts, and with other community and professional organizations such as the San Francisco Emergency Physicians Association to advocate on levels from the organizational to the state levels for medical providers. The path forward now is both sustainment of this effort and an additional awareness of the education and communication needs for resources and expertise to meet the unpredictable challenges of COVID-19 Phase II response.

Finally, the authors encourage individual practitioners to become increasingly active towards adapting their practice to meet these changing needs of society. At baseline we can improve our personal and professional disaster preparedness. Reviewing and updating our plans and supplies using the pandemic tools placed on the SF DPH website at https://www.sfdph. org/dph/alerts/coronavirus.asp is a positive, meaningful effort we can make in this time of uncertainty. Please remember that we are approaching the wildfire and heat seasons in Northern California, so we need an all-hazard approach to meeting the challenge of this next phase. Becoming more aware of, educated about and supportive of efforts to diminish the social inequities worsening the effects of this virus is a crucial step to navigating it successfully. Whether that support is by our providing our time, talents or treasure, a less racist, more health-conscious and educated patient population will result in more resiliency. This will also result in a more rapid transition to our desired endpoint of phase III response where we have effective medication/vaccination/social controls for COVID 19.

Support activities that the authors recommend include volunteer opportunities for physicians which can be found at the City’s COVID 19 Emergency Volunteer site here: https://app.smartsheet.com/b/form/cae0ff0cbe4f417986e817272f527b8b. or by contacting DHR-EVC@sfgov.org. Others are paid opportunities to work at San Francisco’s alternate care facilities as they become available during the surge will be posted here: https:// www.helunahealth.org/ under “Join our Team” and “Current Job Openings”. Finally medical positions to help with the surge response at the state, federal and Community Based Organization levels can be found on the EMS Authority https://emsa. ca.gov/disaster-healthcare-volunteers/ and numerous other websites.

As Her Majesty, Queen Elizabeth II said in her speech early in Phase I, “let’s get through this together and we will see each other again.” Let us keep faith in our collective accountability and the power we hold, together, to shape the course of this pandemic.

Dr. Ramachandran is a third-year resident in emergency medicine at the UCSF Department of Emergency Medicine with a background in public health and an interest in local and global disaster response.

Dr. Brown is the Medical Health Operations Area Coordinator for the San Francisco Department of Public Health, an emergency physician practicing at San Francisco General Hospital and a Medical Officer on the Disaster Medical Assistance Team CA-6.