pandemic lessons

Past outbreaks, and national history, inform hospitals’ response to COVID-19

BY YIWEN LU

It has been more than five months since a stay-at-home order was first issued in Illinois due to the novel coronavirus pandemic. Despite limited reopening of parts of the U.S., COVID-19 continues to devastate many communities. The number of deaths has reached more than 180,000 as of August 31, making this the secondmost fatal pandemic in the U.S., only outnumbered by the 1918 Spanish Flu’s 675,000 deaths.

The country has also seen more recent global pandemics, but none of them have affected the U.S. as dramatically as COVID-19. During the 2014–2016 Ebola outbreak in West Africa, which ended with more than 28,600 cases worldwide, the U.S. Centers for Disease Control and Prevention (CDC) trained more than 6,500 U.S. health care workers, but in the end, only eleven people were treated for Ebola in the United States. Between 2009 and 2010, the H1N1 swine flu pandemic caused an estimated 60.8 million cases in the U.S. and resulted in 12,469 deaths. Back in 2003, the SARS outbreak lasted for nine months, but there were only eight confirmed cases in the U.S. and no deaths.

Now, in dealing with COVID-19, the health care system’s current strategies for managing a pandemic are under scrutiny around the country, including in Chicago. “What coronavirus has done is that it exposed chronic problems with how infectious diseases are handled,” said Dennis Kosuth, a part-time nurse at Provident Hospital in Grand Boulevard. Kosuth was involved in the protest against the closure of Provident Hospital’s emergency room in early April, when the pandemic had just started to significantly hit Chicago. To Kosuth, the closure showed incapacity for a COVID-19 surge and the deep roots that caused it. “[This happened] not because people aren't smart or doctors don't know what to do, but that the health system is all based around profit, rather than based around what people need,” he said.

Looking at where we are today in the history of pandemics in the U.S., and the history of the federal government’s management of medical supplies for pandemics and other emergencies, we can see what we’ve learned and been able to apply to COVID-19—and what we’ve failed to address.

While Ebola was deadlier than the novel coronavirus that causes COVID-19, the CDC was able to efficiently contain it in the U.S., in part because the disease was not spread by respiratory droplets, according to Dr. Emily Landon, executive medical director of infection prevention and control at the University of Chicago Medicine. At the time, UChicago Medicine tested and isolated potential patients who came to the hospital. But in the end, there were no confirmed cases, John Hieronymous, a nurse at UChicago Medicine, told the Weekly. (The Weekly attempted to contact four other hospital systems on the South Side, but none responded.)

During the H1N1 flu pandemic, however, with the need in the U.S. orders of magnitude greater, the hospital experienced a stretch in intensive care units (ICU) and supply capacities. Many health care centers and governments in the U.S. had begun to prepare plans for disease outbreaks during the 2003 SARS epidemic and 2005 avian influenza outbreaks, according to HealthDay News, and were able to benefit from activating those plans. But in the reality of a pandemic, there was more to learn. Landon told the Weekly that UChicago Medicine’s experience with H1N1 taught the hospital to use its supplies “smartly,” to screen patients at entry so that they could be more promptly isolated, and to restructure the design of the emergency room.

“When we built our new emergency room, we built a pandemic wing, so that we could change the airflow quickly and lock off a number of rooms. They could be used for exactly this [COVID-19] scenario,” she said. “We were able to make use of the stuff that we invested in because of what we learned from 2008.”

In addition to making the emergency department more compartmentalized than before, allowing patients to be better separated from each other, Landon said that the new building construction also allowed the hospital to expand its ICU capacity in many more rooms.

While hospitals have learned from past pandemics how to improve their infrastructures in response to increased demands for medical treatment, the supply chain still lags behind.

Though UChicago Medicine, for example, built ICU capacity and the ability to separate patients into its physical infrastructure, bolstering its ability to handle a pandemic, Hieronymous, who was involved in the organizing efforts at National Nurse United, is concerned that its supply management strategy still makes the situation “chaotic.”

Like most American hospitals, UChicago Medicine uses just-in-time logistics, meaning that the hospital only purchases medical supplies needed for a few days or a week. Because it would be costly or potentially wasteful to stockpile more vaccines, drugs, and disposable equipment, keeping the inventory low seems to these hospitals to be the most efficient option.

In a pandemic, there are fewer options when critical supplies run low. “There is no wiggle room in the system. Everybody is impacted negatively, so that ability for the system to flex and provide support in a local or regional area is not available,” said Chris Martin, a spokesperson for the Illinois Nurses Association.

Hieronymous alleged a just-intime strategy left UChicago Medicine “completely unprepared.” “With changes happening day-to-day, it was clear that there was no set plan. There were no supplies

UChicago Medicine converted roughly 7,000 square feet of space into COVID testing/treatment space in early March, shortly after cases started to spread in Chicago.

stockpiled,” he said. And in late April, as shortages of personal protective equipment (PPE) for health care workers were being reported nationwide amid a huge increase in demand, other UChicago Medicine nurses noted supply pressure. "Our faces are bruised and blistered from nonstop use of masks of all kinds. We go hoarse from our inability to hydrate, since we are instructed to conserve PPE, and we need to yell through masks to be able to be heard in normal conversation," critical care nurse Cassandra Callaway said during a rally at shift change over concerns about being overworked and understaffed, according to the Hyde Park Herald.

In an email to the Weekly, Eric Tritch, the Supply Chain & Logistics Vice President at UChicago Medicine, said that it’s “100% untrue” the hospital was not prepared for COVID-19 and that the preparation process started as early as January.

“UChicago Medicine maintained (and continues to maintain) regular inventory management safety stock plans in conjunction with local, state and federal guidelines. Obviously, the impact and the duration of this pandemic is more than anyone expected to see, but UChicago Medicine’s supply chain quickly responded to bring in the products needed to keep staff and patients safe with PPE and other supplies,” hospital spokesperson Jamie Bartosch wrote in an email.

But whether supply management posed problems at UChicago Medicine or not, the contention over the issue—multiple hospitals in Chicago saw nurses alleging they had minimal or insufficient PPE early in the pandemic’s course in Chicago—highlights that potential problems with “just-in-time” business practices in a pandemic have been criticized for years, going at least as far back as 2006. Public health advocacy group Trust for America’s Health issued a report that year concluding that thirty-five states were not fully prepared to distribute emergency vaccines, antidotes, and medical supplies from the national depository, and half of states did not have enough hospital beds to meet estimated need within two weeks of a moderately severe pandemic flu outbreak.

Federal government actions around that time highlight its role in maintaining a status quo without significant stores of supplies. In November 2005, George W. Bush’s White House unveiled a report on the possibility of implementing a national strategy in the face of a flu pandemic, for which Congress appropriated $3.8 billion, far below Bush’s request. Though the White House Homeland Security Council then issued such a strategy and an implementation plan, neither have been updated since 2006 (though at least one plan issued by another

PHOTO COURTESY OF U OF C MEDICINE federal agency has been). And these, like most other federal response plans for pandemics, do not involve a “broader, allhazards approach,” according to the Center for Health Security at Johns Hopkins School of Public Health, and the federal government still “lacks a publicly available plan for how to identify, characterize, and develop medical countermeasures against a novel pathogen.”

Even before the influenza plan, the federal government had long been unwilling to pay manufacturers to stockpile vaccines. The Strategic National Stockpile (SNS), a national repository of critical medical supplies, including vaccines and antibiotics, was hamstrung in early 2005 when three out of four companies that used to supply children’s vaccines to the SNS withdrew, citing Securities and Exchange Commission (SEC) accounting guidance as the reason. The guidance said revenue for the vaccines would not be recognized until they were delivered to customers, meaning that when companies produced vaccines for the federal stockpiles, they would not be immediately paid.

At the start of the next flu season in December 2005, the SEC issued an interpretive release stating that vaccine makers could recognize the revenue when the vaccines were placed into the federal stockpile, regardless of whether they were delivered. The U.S. has not experienced major shortages of flu or childhood vaccines since.

But the SNS has continued to face problems when it comes to other supplies years later. A 2017 study funded by the National Institutes of Health and the CDC found that supplies in the Strategic National Stockpile “might not suffice to meet demand during a severe public health emergency.” The SEC accounting seems to still play a role; in an updated 2017 guidance, the 2005 interpretation was reaffirmed, yet it also specified that “it is not applicable to transactions other than the sales of enumerated vaccines by vaccine manufacturers.” A Competitive Enterprise Institute blog post interpreted this to mean manufacturers of ventilators, PPE, and other important medical supplies would not be able to immediately book the revenue under the guidance, and thus they might lose revenue if they contribute to the stockpile of federal supplies. In the case of ventilators, one machine costs thousands to tens of thousands of dollars.

A disease like COVID-19 undoubtedly puts unusual pressure on ventilator resources, but the problem is never new. A CNN report in March 27 detailed more than ten government reports in the past two decades that warned about a critical lack of ventilators when facing a viral outbreak.

As Marcia Crosse, the former director of health care at the Government Accountability Office, told CNN, “The CDC has been well aware, [the Department of Health and Human Services (HHS)] has been well aware, the intelligence community has been well aware...of course, nobody would know the specific details, we didn’t know it would be a coronavirus from China, but the threat of a respiratory illness was known.”

The SNS plays a major role in preparing supplies for pandemics, but it’s only one of a number of ways that the federal government can affect supply management. In one example that touches on hospitals more directly, in February, the Trump administration proposed a budget plan for the 2021 fiscal year that included lower hospital reimbursements, a $465 billion cut from Medicare, and a nine percent reduction in HHS funding. More hospitals and health care organizations then would tend to turn to just-in-time supply management strategies as they face tighter profit margins.

“As a country, we may have gotten a bit complacent, and we have underfunded public health. We saw the effects of that with the inadequacy of testing, and there [are] not enough people to do all the contact tracing,” Landon said. “It wasn’t possible for us to contain this epidemic, not because we don’t have the sufficient facilities, or because we don't have great enough hospitals, but because our public health system was not strong enough to be able to do it.”

“If this country wanted to get in front of it, what they should have done was [to] get on the phone with the infectious disease doctors in China back in January when it was clear that it was going to be becoming a problem around the world,” said Kosuth. “The people who run this government are so racist that they don’t care about people dying, they would have no problem with that.... They don’t run health care in a sensible way. [They run it] for making money.” ¬

Yiwen Lu is a reporter for the Weekly who primarily covers politics. She last wrote about South Side artists finding ways to continue their work and support their communities through the COVID-19 pandemic.