All About Change - Season 3, Episode 7: President of Massachusetts General Hospital Dr. Peter Slavin on Covid-19 and When We Can Expect a Vaccine

Episode Date: July 13, 2020

On the new episode of All Inclusive, Jay has special guest, Dr. Peter Slavin, President of Massachusetts General Hospital. Jay and Peter discuss the potential for a vaccine for Covid19 on the horizon and the impact of the pandemic on society and the medical community.See omnystudio.com/listener for privacy information.

The COVID-19 pandemic has put a spotlight on our frontline healthcare workers. Many of them have worked hard to take care of people close to you and me. One of the renowned hospitals leading the charge against the pandemic is Massachusetts General Hospital in Boston. General Hospital in Boston. All Inclusive, a podcast on inclusion, innovation, and social justice with Jay Ruderman. Hi, I'm Jay Ruderman, and this is All Inclusive. Today, we have the President of Mass General, Dr. Peter Slavin, joining us. Dr. Slavin, thanks for joining us on All Inclusive. I want to begin by thanking you and the first responders who worked hard during this past year and continue to do so during the pandemic, and for your dedication in advising leadership

from all over the world on the best ways to tackle this terrible illness. Tell us how has MGH reacted initially to the pandemic, and are there any procedures that you will continue to implement, especially with the potential for a second wave? Well, thanks, Jay. It's a pleasure to have a chance to talk with you. I could go on for a long time about the different ways in which we responded to this unprecedented situation, but I guess I'll focus on three. One is the care itself. I mean, we had to turn the hospital inside out and upside down to respond to the demands that we saw beginning in March that peaked in April. At our peak, we had 450 COVID-positive patients in the hospital. That represents about half of our hospital beds. We normally have one medical intensive care unit

for medically ill people. At that point, we had 12 intensive care units requiring us to redeploy staff, both doctors and nurses, from around the hospital. And we normally have about 40 patients in the hospital on ventilators. I think at our peak, we had about 150. So the effort involved in just responding to that initial surge was amazing. On the outpatient side, our outpatient activity fell by about 50%, but almost 85% of it was now being delivered via telemedicine, something that we did very infrequently in the past. Less than 1% of our outpatient care was telemedicine, something that we did very infrequently in the past. Less than 1% of our outpatient care was telemedicine prior to February or March. It went up to 85%. It continues to run at about half of our overall outpatient activity. So that's one area.

Second area that I would just focus on is the research effort. We have the largest research program of any hospital in the country. And both the fundamental as well as the clinical research effort that we launched has been remarkable to see. We're involved in multiple trials and possible therapies for COVID-19. We were involved in the one that showed that remdesivir was somewhat effective in shortening that illness. And we have two vaccine candidates that are in the works in various stages of development. So the research has been very exciting. And then the third area I'd comment on is just the incredibly dramatic connection that we've seen between what's happening in the hospital and what's happening in the community. At baseline, about 10 to 15% of our inpatients of Mass General are Spanish-speaking people. And we noticed pretty early on that when it came to our COVID-19 patients, almost half of them were Spanish-speaking, which made it very clear that they were coming from Revere, Chelsea, and East Boston. And so we

unleashed a major community health effort in partnership with the leaders of those communities to try to stem the illness, mitigate the disease as quickly as possible. And so it was a real demonstration of the power of the social determinants of health to result in this virus so disproportionately affecting disadvantaged communities like those. So I wanted to maybe delve into a couple of those issues a little bit more deeply. Probably what most people want to know is how far away are we from a vaccine? And I'm sure there are institutions all over the world that are working on vaccines. How much coordination is there between hospitals and private enterprise in trying to find a vaccine? I believe there are over 100 vaccine candidates at various stages of

testing around the world. As I said, we were involved actively in two of them. I think the more the merrier because coming up with an effective vaccine is part science and part luck. Just using a sports analogy, the more shots on goals we take with vaccines, the more likely it is that we're going to develop one or more that are safe and effective. And in addition to just coming up with a vaccine, there's no company, no organization that can individually produce all the vaccine necessary to vaccinate everyone around the world. And so we're going to need multiple candidates and multiple manufacturing facilities to be able to meet the demand. So I'm hopeful if we get lucky, we could have a vaccine that's shown to be safe and effective by the end of this year,

and maybe in production early next year. But I think we're going to have to get lucky for that to happen. And if we do get lucky, the production of that vaccine will take some time. It won't happen overnight. It won't happen overnight, but because of the unprecedented investments that are being made, it'll happen a lot sooner than usual. For example, in the case of one of our vaccine candidates, that's actually the work of an investigator who's based at the Beth Israel Deaconess. That vaccine has been picked up by Johnson & Johnson and the federal government. While the clinical trials are ongoing related to this vaccine, the production facility is already being built and fitted out. And so the federal government and J&J are investing a huge

amount of money so that if indeed the clinical trials are favorable, they can swing into production almost immediately. Another issue that you talked about is telemedicine, which I myself have been involved with my doctor, and it's been very successful. Is that the future of medicine? In terms of telemedicine, I don't think it will completely replace medical care as we know it, but I think it can replace a fair amount on the outpatient side. I mean, you can't really do an adequate physical exam via telemedicine. You can't do procedures on people via telemedicine.

You can't do fancy radiology images like MRI. By telemedicine, you can't do fancy radiology images like MRIs by telemedicine. But there's a lot of visits that can be done remotely. I mean, there are a lot of, for example, cancer patients who see their oncologist on a regular basis, basically go over the results of the scans that have been done. Scans will still have to be done in person, but there's no reason why that visit couldn't potentially be done remotely. You talked about minority populations being overly affected by COVID-19

and the amount of Spanish-speaking patients in the hospital. I know you've talked about this in the past, but do you know why that is the case? I mean, I think it all comes down to the, historically referred to as the social determinants of health. People in those communities have more crowded housing conditions, which makes it more likely that the disease is going to be spread if one person gets it. People in those

communities are essential workers and therefore have to go to work. And so that puts them at higher risk. I think there was a study that was published in the New York Times about two months ago, which compared using cell phone GPS technology, movement of people in affluent communities in this country, as opposed to lower income communities. And it was quite clear that in the affluent communities, people were basically sheltering at home. And in the lower income communities, they were going to work and leaving the house much more frequently. So I think that put people at risk. Can you talk a little bit about the financial impact on Mass General Hospital, which I'm sure is taking place at hospitals all over the country, people putting off elective surgeries and other procedures that would bring income into the hospitals.

What's been the financial impact on the hospital? Just to clarify, we instituted a salary freeze, so we're not increasing people's salaries for the time being, except for people whose incomes are less than $55,000 a year. This pandemic has had a very significant impact on our finances. For several months, our outpatient activity was about half of what it normally is. That took a big toll on our revenue during that same period of time. Our expenses didn't really change much at all. And on the inpatient side, we also saw a temporary downturn, but that sort of bounced back more quickly. And we obviously had lots of very

sick COVID patients in the hospital. We have received some support from the federal government, so that has helped us offset some of the losses, but we're still lost significantly as a result of this pandemic. I want to talk a little bit about the mental health of first responders, doctors and nurses, other people working at the hospital and coming to the hospital as first responders. We, our foundation, was proud to partner with MGH to support the hospital and

healthcare workers regarding mental health. Can you talk a little bit about the programs that are being offered to frontline hospital workers and how they're dealing with issues of mental health? I mean, I think the psychology of this for the staff has been complicated. I think on the one hand, our staff have the privilege of caring for people and being involved in our society's biggest challenge in our lifetime. Our staff is very used to caring for complicated sick patients. And so I think that played to their strength as well. But I think the sheer magnitude of it was overwhelming. The suffering that people witnessed was overwhelming. Having to care for patients without their loved ones around, I think was very difficult, not only

on the patients and their loved ones, but the staff themselves. And finally, the fear associated with caring for these patients, not knowing if you were going to get sick, not knowing if you were going to bring the disease home to your family. I think the combination of emotions, feelings is complicated. And so it definitely took a toll. I mean, we bent over backwards to try to support our staff during this period of time. I mean, we have a very active employee assistance program that has made itself available to our entire staff. On some of the units that were caring for lots of COVID patients, we had these regular sessions where people could talk about the experience that they were going through. And I think they found those comforting. We also were overwhelmed with support coming from outside the organization, which I think

our staff greatly appreciated. I don't think there was ever any period in the history of our hospital where our staff was better fed than they were during the last few months. We just had countless donations and meals. So, I mean, it was pretty overwhelming to see the amount of external support. And I think our staff really appreciated this. I don't think we're really going to know the full toll that this has taken for months or years. In some ways, I think it may be similar to what we've seen with soldiers returning or veterans returning from Iraq and Afghanistan, suffering from the invisible wounds of war. I think there will be some people who are permanently scarred by this, what they've been

through over the last few months. And we have this program in collaboration with the Red Sox called the Home Base Program for veterans suffering from post-traumatic stress. And we have this program in collaboration with the Red Sox called the Home Base Program for Veterans Suffering from Post-Traumatic Stress. And we're in active discussions with that program about whether they could potentially broaden their services to make themselves available to healthcare workers as well. You're listening to All Inclusive with Jay Ruderman. You can learn more. View the show notes and transcripts at rudermanfoundation.org slash allinclusive. Please remember to subscribe, rate, and review us wherever you are listening. As a society, what have we learned and what has the government learned from this pandemic?

In the event that there's a spike, that there's a second wave or a different pandemic presents itself and we have to go through this all over again? I hope our government is educable. Obviously, the response around the country has been highly variable and uneven quality. I'm particularly pleased with what's happened here in Massachusetts. I think the Baker administration has done a very good job working with the healthcare community, working with people throughout the state to try to balance dealing with this pandemic with trying to sustain our economy in some way. And I think understand that you can't really sustain the economy without first and foremost controlling the virus. So if we're proud of the fact that at least at the moment, Massachusetts has the lowest rate of transmission in the country. The number of cases that we're seeing on a daily

basis is quite small. I think one thing that we've learned is that previously in healthcare, we were focused on just-in-time inventories of supplies. That was all supplies, drugs, personal protective equipment, et cetera. And I think that approach to inventory management didn't serve us well during this pandemic. So I think individual providers are going to have created more inventory for needed supplies. The state government has done the same. And I hope the federal government has done the same as well. So if indeed there's another surge, and we're certainly seeing it in substantial parts of the rest of our country, hopefully we'll be ready from an equipment standpoint than before.

And we certainly know how to dial up our capacity if needed. So other states that we see the COVID pandemic surging right now, like Florida, Arizona, Texas, what can they learn from Massachusetts, that Massachusetts has sort of gotten over the first surge, and the numbers have calmed down? It's not really very complicated. I don't think you can really reopen society until the transmission rate is at a very manageable level. To do otherwise is just playing with fire. And I think, unfortunately, that fire is at the moment out of control in certain parts of with fire. And I think, unfortunately, that fire is at the moment out of control in certain parts of our country. And I certainly hope they can get it back under

control. But when you see, I believe it was in, I don't remember if it was Florida or Texas, that 20 or 30% of the tests that are being done are positive for COVID-19. In Massachusetts, that number is about 1 or 2%. So it's quite clear that some of the states in this country just reopened the economy, allowed people to mingle with one another far before they should have. To the extent that there are rules in those states about social distancing and wearing masks, there are too many people who aren't paying attention to that and violating those rules, putting themselves and others at some degree of peril. It's unfortunate that what seems to be a common way to deal with healthcare by asking people to

wear masks has in some ways become somewhat political, which is unfortunate. I hope that people will realize that they can save lives, their own or others, by wearing a mask. But, you know, we're an open country. People travel from place to place. It's still, people are still able to travel either by, you know, airplane or in a car. What happens if people from other states where the virus is surging come here? I think it's potentially trouble. And we own the hospitals on Martha's Vineyard, Nantucket.

They, about a month ago, more or less had no cases on those islands. And now there are a couple of new cases appearing almost every day from other states, people who weren't aware that they had the disease but developed symptoms and are positive. So I think we're seeing before our eyes that this disease will be introduced to a greater degree into our state by interstate travel. I just hope those other states will really clamp down hard on social distancing and mask wearing, not only for their own sake, but for the sake of places like this as well. Every state is different. The governance is different. I particularly noticed that in Israel, with a similar size population, they've been able to keep their deaths down to under 400,

whereas in Massachusetts, we've reached over 8,000. Any idea why that happened here in a state that took it very seriously and had very strong leadership in addressing this? I haven't seen any good comparative data between us and Israel. I would point out that probably more than half of those deaths occurred in people living in nursing homes, and I'm not meaning to trivialize those deaths in any way, but I believe here in Massachusetts, 95% of the deaths occurred in people 70 or older, only 5% of people 69 or younger. So this is clearly a disease that disproportionately affects older and sicker folks, and particularly those in nursing homes where this can spread like wildfire. But I don't know enough about what we did compared to what Israel did to know what resulted in the difference in the outcomes. They swiftly locked down all foreign travel and sort of isolated the country very quickly.

And I think one of the reasons that Massachusetts, New York became hotspots early on is because of the amount of travel from Europe, from Asia that comes here, which in most times, most cases is a good thing, but certainly may have hurt us this past spring. is a good thing, but certainly may have hurt us this past spring. So we released a white paper with a bioethicist out of University of Pennsylvania, Dominic Sisti, that looked at the allocation of resources during a pandemic with regard to people with disabilities, as well as others with underlying illnesses. It's my understanding that MGH never ran out of ventilators, but did the hospital leadership discuss what was going to happen and who was going to decide who would get one and what criteria would be followed if there was a limited number of ventilators and more patients that needed them than you had? Yes, we did have an active debate about that issue. We had it not only at the

hospital, but at the health system, as well as at the state level. And I mean, I found it to be one of the most interesting and challenging debates that occurred during this pandemic. Fortunately, we never had to implement what are referred to as these crisis standards of care, but we did make significant progress in developing them. I guess at one extreme, you could think the ventilator should be allocated based on who needed it first. And if you, and just do it by the order in which patients come in, I guess another approach would be to make some judgment about how likely it was that people were going to survive this illness and how, what their quality and length of life was likely to be once the illness was over. And I, at least personally, was initially very attracted to the latter approach. It seemed like that would be the

most utilitarian way to allocate the ventilators. But you realize as you head down that path that since certain people in our society with comorbidities, which tend to be more prevalent in minority communities, that you can quickly find yourself in a situation where you could potentially be allocating these resources in a way that was racist or discriminating to certain groups. So it's a very challenging issue. I think at the state level, after some initial approaches that were more along the lines of the latter approach. I think the state sort of backed up a notch or two and tried to, again, put in place criteria that would allocate these resources to people who would benefit from them, but at the same time, try to avoid discriminating by any categories that would be objectionable based on disability, based on race, based on age, based on ethnicity,

et cetera. But it is a very challenging and obviously critically important issue. And I hope we never have to implement these crisis standards of care during my lifetime. But again, these crisis standards are being developed state by state. There's no federal guidelines as to how to handle these types of situations. That is correct. There were guidelines that were issued by the state of Massachusetts, but they were guidelines to hospitals and providers. And we had some experts in this field that were very actively involved in the development of those guidelines. some experts in this field that were very actively involved in the development of those guidelines. But I think we all breathed a sigh of relief when the numbers started heading in

the right direction and we never were forced to implement them. My sense is that the public really wants desperately to get things back to normal. Do you think there's a point when you would feel comfortable not wearing a mask, not social distancing at a big event where people would be able to go back to restaurants and bars and concerts and ball games, sort of like being over, are we ever going to reach the other side or is our life permanently going to be changed? Well, I don't think it'll be permanently changed, but I think it's going to be changed in all likelihood until we have a vaccine that is, or vaccines that are widely distributed and through a vaccine, we've achieved herd immunity. And until that time, unless you

know you've been exposed to the disease and have protective antibodies, I wouldn't advise the kind of activity that you're describing. So I think we are in a holding pattern. I mean, clearly now that we have serology testing, some people do know that they've been exposed. We're not sure yet whether that exposure confers immunity. So it's probably wisest for everyone to be careful until they're certain that either on an individual or a population basis we're protected. This is a very nasty virus, 10 or 20 times more lethal than influenza. And although most of the deaths occur in older folks, certainly not all of them. And if you look at how frequently people get hospitalized, and I think at our hospital and around the country,

about 40% of the hospital beds utilized by patients with COVID-19 were among people younger than 60. So young people can get very sick. They tend to survive, but they're in for a pretty serious illness in some cases. When we had the last major pandemic, I mean, there's been several, but the big one in 1918, I'm not sure, I don't know if you know, if there was a vaccine that was produced at that time, but it seemed like after a period of time, after several waves and many deaths, that it went away. Is there something about a virus that sort of runs its course? I believe that that happened before vaccines were available, so it just, it did have to run its course? I believe that that happened before vaccines were available. So it just,

it did have to run its course. And obviously there were no viral therapies available back in the early 20th century. Viruses and infections in general do tend to peter out when about 60, 70% of the population has been infected and is immune. It's just as harder for the virus to find somebody at that point that is uninfected. In epidemiology, there's this transmission rate factor of R, and if R is greater than one, the virus or the infection will grow exponentially. If it's less than one, it will decay and eventually disappear. Here in Massachusetts, we're just right at about one. In other states, they're significantly over it, and we're seeing exponential growth of the infection. So the key is to get R below one, and then you see decay in the number of cases over time. And that's what's required for it to eventually disappear. I mean, we've been through one significant wave in this region and places like New York,

but the best estimates are that only about 10, 15 percent of the population has been exposed. So there are a ton of people who have had no exposure to this virus. And if those people were to get exposed all at once, there's no doubt that it would overwhelm our health care system. The key between now and when a vaccine is available is to just make sure that ongoing spread happens slowly. We can't eradicate it, but we can hopefully keep it under control so that it progresses slowly,

hopefully primarily in the younger people who are less likely to die and just not at a rate that overwhelms the healthcare system. And again, here in Massachusetts at this moment in time, we're doing that. And hopefully that will continue as we move through the various phases of reopening and as other parts of the country get their problem under better control. Yeah, I want to thank you for your leadership. There have been cases where there's been lack of leadership on various levels of society. And I think that that contributes to the fact that people are not taking the precautions that they need to protect themselves and others. But I wanted to ask you, you run a major

institution, healthcare institution at the forefront. This has been going on for many, many months. You must be dealing with a lot of personal stress. How do you handle this personally? And how do you take care of yourself and your family during this time in order to continue to lead such an important institution? That's a good question. I don't want to dwell on myself. I don't want anybody to feel sorry for me. But certainly during the height of this, it was sort of nonstop, seven days a week. Life has returned to more normal now that the number of cases are under control and we're providing lots of other care as well. But I'm

working, as you can see right now, a fair amount from home. And because most of my day is, rather than being in person-to-person meetings, is in Zoom sessions and conference calls and phone calls. And so not a whole lot of sense for me to sort of go into the hospital and sit in my office by myself when I can do that from home. So I'm practicing what I'm trying to preach about remote work. This has been a stressful time. I mean, we are now, as I said to several groups in the hospital via Zoom, dealing with three epic issues. Any one on its own would be enough to keep us occupied, but we're dealing with three simultaneously. One is the virus and the pandemic and how to continue to care for patients with it while we expand the number of

other patients that we're caring for. Second is dealing with the financial consequences of COVID-19 and steadying the financial ship of Mass General. And then lastly, this issue of racism and social justice, which has emerged so significantly in our society at this time. And so we're just thinking about how can we, within our walls and more broadly, take dramatic steps to combat racism and advance social justice. And I think this is a unique opportunity in our history to bend the arc of the moral universe toward justice. And we're committed to doing that as well. Has Mass General begun to delve into the issue of racial inequality? From my own experience, you know, my mother had a very serious heart issue, was hospitalized for

a while at Mass General last summer. She had excellent care, and the doctors and nurses were of all different ethnicities, races, religions from all different parts of the world, and just, you know, top notch. So in my opinion, I think Mass General was in a good place to start with, but I'm sure you've done extra work seeing the national discussion on racial injustice that's happening, you know, throughout all sectors of society. No, I think it's something that we've been focused on. I think we've certainly made progress over the years, but I think we recognize that there's a lot more progress that we need to make. I'm delighted to hear that your mother's experience was a positive one. We do benefit from a very talented workforce that comes from all over the world. And I worry a lot about our

current immigration policies and the impact that's going to have on the quality of what we do in the long term. But there's a lot more that we can do on the racial social justice front. And so we're finalizing a set of initiatives that we will launch. We're going to be reviewing them with our board later this month. And we want to, again, use this unique opportunity in our history and our lifetimes to significantly advance the issue of equity within our organization. And I think there are lots of ways that we can do it. Well, Dr. Slavin, thank you so much for joining us today. This was extremely informative. Again, I want to thank you for all the work that you and your staff has done to keep our community safe and to help the world in general. So I know you have a lot of hard work ahead of you, but thank you for taking the time

joining us today. Well, it's an honor to do that work and pleasure spending some time with you. Be well. Take care. All Inclusive is a production of the Ruderman Family Foundation. Our key mission is the full inclusion of people with disabilities in all aspects of society. You can find All Inclusive on Apple Podcasts, Google Play, Spotify, and Stitcher. To view the show notes, transcripts, or to learn more, go to rudermanfoundation.org slash allinclusive.

Have an idea for a podcast? Be sure to tweet at Jay Ruderman. Thank you.