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MIT Technology Review
Coronavirus

Here’s what a New York City ER doctor says about covid-19 wards

Dr. Craig Spencer shares what its like to treat covid-19 and how its hurting the most vulnerable communities.

April 8, 2020

Update: This episode has ended.

In this episode of Radio Corona, Gideon Lichfield, editor in chief of MIT Technology Review, spoke with Dr. Craig Spencer, director of global health in emergency medicine at Columbia University’s Irving Medical Center. They discussed what it’s like to treat patients with covid-19 in New York City, hospital preparedness, and pandemic response. 

Spencer is an emergency room doctor in New York. He also worked during an Ebola outbreak in West Africa several years ago, and is an Ebola survivor himself. You might have seen Spencer’s viral Twitter thread about what it’s like in an ER right now.  

This episode was recorded on April 9, 2020. You can watch it below.

Gideon Lichfield: With me today is Dr. Craig Spencer, who is a - I'm going to get your title completely wrong, Craig, I'm sorry, why don't you introduce yourself and let's do this properly.

Craig Spencer: Absolutely. So yeah, I'm the director of Global Health and Emergency Medicine at Columbia University Medical Center. Basically I'm an emergency medicine doctor here in New York City.

Gideon Lichfield: Right. All right. Thank you. And Craig is also known as I think of being the onlyNnew Yorker and one of very few Americans to have actually contracted Ebola and survived, back during the Ebola pandemic. So we're going to be talking about a lot of different things today, particularly in the situation of healthcare workers and the state of the pandemic in New York and around the rest of the country. You can submit questions for Craig if you're listening by putting them into the comments box on Facebook or in YouTube, I will see them and I will put them to him. So Craig, thank you again for being with us and thank you for the work that you're doing, which is incredibly important and dangerous, and vital for everyone. So let's start off with the, you know, people have been talking about the shortage of masks and protective equipment and other equipment in the hospitals for a long time. How was it now compared with what it has been in the past few weeks?

Craig Spencer: It's variable and I think that's how we characterize this whole pandemic year in New York City. Like some hospitals are okay, some hospitals absolutely are not. I have the benefit of working at one of the best hospitals in the world. So PPE hasn't been as big of an issue for me as it has been for a lot of my colleagues who throughout the city are talking about, you know, one mask, one N-95 mask a week, one surgical mask a shift, having pretty low standards are much lower than anything that we're used to. So again, it's just been super variable. I have friends, obviously working in every ER all throughout the city. We're a pretty closely knit, tight community. I'm on five or six different WhatsApp groups. You know, being updated on what's happening in the Bronx and Brooklyn and Queens. I'm in Manhattan where the numbers aren't nearly as bad as they are in every other borough. And so kind of what I'm seeing is bad, but I know that what my friends and my colleagues are seeing in their ERs is in many respects even worse, especially in regards...

Gideon Lichfield: ...well how come you, how come you have better access to PPE? Is that because you have fewer patients or is the hospital somehow better stocked? How come...

Craig Spencer: It's just, I think it's a bigger hospital system that just has a bigger supply chain and just has, you know, just has a lot more to pull on. Right? Like we just have a bigger number of things as opposed to a smaller hospital or a smaller hospital system, which may not have the same amount of reserve, may not have the same stock. So I think we're just, we're just a bigger place as opposed to some of these other hospitals that might again, might not have the same access to the same stock reserves and other...

Gideon Lichfield: Isn't it a little crazy that every hospital system has to fend for itself in this regard?

Craig Spencer: Yeah, I mean it's, this shouldn't be the same, it shouldn't be like this in the hospitals and I will say here in New York State, obviously Cuomo has, Governor Cuomo has taken some action to kind of pool our resources in a sense. Ventilators moving things from upstate to downstate where, you know, they'll just move right back up when the pandemic goes up there. This is smart, but this is something that should have been happening at a federal level, not at a state level, not even at a city level. This is something that should have been happening on a much greater level of cooperation across the federal government much earlier on as opposed to having everyone kind of scrounging and fighting for supplies and an open E-bay market basically.

Gideon Lichfield: Right. And is there any sign that you can see that that equipment situation is starting to get better or maybe at other places? Is the supply chain improving or is it still very, very hit and miss?

Craig Spencer: I think it's hit or miss. I guess I'm still hearing from friends in Ohio, in other places in Arizona, all throughout the country that are talking about how their supply chain is weakening because there's a lot is being diverted as it should be to places on the front line so that we have enough, I mean if everyone understood how much supply we burned through on a daily basis, talk about thousands and thousands and thousands of healthcare workers and other people using mask, gowns on a daily basis. And we go through tens of thousands of these things. We can go through millions of masks in a month. So we talk about, you know, increasing the supply by millions of masks at one factory over the next month. That's great. But that might be enough for one hospital in one city for that period of time. Like we need a huge supply and right now that's starting to come in, we're hearing about an increase in production, and it's great, but it's still really tenuous at our hospitals and certainly will be going forward for other places unless we have a huge increase, which I'm hoping we see soon.

Gideon Lichfield: Right. One of the other big concerns obviously is burnout and trauma among healthcare workers. I mean you are the people on the front line the way that the firemen were in 911 except you are going in day after day after day. Talk to me about what you're seeing there.

Craig Spencer: I have a lot of experience with this working in West Africa in 2014. There I work six often seven days a week, 12 hour, 14 hour days, taking care of Ebola patients physically exhausting. We'd get out of the tent, you know, pour out your boots and you'd have a liter of water in there. Everyone was required to take, you know, a liter and a half of water after you get that out with oral rehydration solution. Basically salts and sugars to rehydrate wet.

Gideon Lichfield: He was sweating into your boots

Craig Spencer: It was just sweat. Yeah, yeah. Right. And it was so super dehydrating. So it was physically taxing, but that was the easy part to fix, I mean it's a mental exhaustion. The mental anxiety is this interaction is today the day that I was infected, you have to wait for a week or two weeks until you really know for sure. That was really, really tough.

I'm seeing those parallels right now with my colleagues. So many of them who did not sign up for this, you know, every one writes, I'm ready for whatever comes through the front doors. Man, you didn't sign up for this, but they're showing up for this. We might not necessarily have the right, it's the right support or even the right kind of mental capacity to handle doing things that we're doing right now, which is not really in our wheelhouse. We generally put people on ventilators. We don't ever take them off, but that's something that we're being asked or forced to do with patients. You know, using, talking with palliative care, talking with family members, like withdrawing care. The first time I've ever withdrawn care in my life in the emergency department.

Gideon Lichfield: Because there's a specialist who does that normally?

Craig Spencer: Well it's just, we just generally don't do that in the emergency department. Like we put people on a ventilator and we bring them to the ICU and you know, right now we have less of a concern about a lack of ventilators. There has been an increase in production thousands were given by the government of China, some more from the state of Oregon. It's like it's still a pressing concern. We want to make sure we have enough. So it's not that we're withdrawing care for lack of ventilators, it's just that we know a lot of people that we put on mechanical ventilation we put on life support have a near zero chance of surviving. So do we talk to the family beforehand? Do we have an opportunity to have a discussion where they can video in because people can't be present in person. Video in to have that discussion before we do that, you know, the hardship that this is going to happen, the patient as well as on the family. Discuss the likelihood of survival for someone who is, you know, in their late eighties really, really sick with a bunch of other comorbidities, the likelihood that they'll come off a ventilator is near zero. So we have that discussion. We don't force anything on anyone, but we have a very Frank open discussion with our professionals in palliative care. And a lot of the times people decide that they don't want to have these really aggressive measures. They want to have a more dignified a more, yeah, really a more dignified death. So that's just something that we don't do. We just, we don't do it. And so we're building up our capacity. We're building up by kind of by, by force our experience with that. But it's still really jarring and it's mentally taxing for us.

Gideon Lichfield: What sort of support and mental health support are healthcare workers are getting?

Craig Spencer: I think everywhere is a little bit different. Institutions are setting up access to psychologists, psychiatrists, things like a Headspace, you know, trying to get people online or in communities. I've been talking to all my colleagues about finding someone to be vulnerable with. So identifying one person, whether it's in their hospital or outside of the hospital, and just to have that space to discuss, to share. This hits everyone really hard and physicians are generally, especially ER docs are generally the kind of people who are meant to be thick skined kind of really tough. We get yelled at by consultants all the time like we can take it. But underneath that, like I see a lot of my colleagues struggling with the physical, but as well as the mental exhaustion. So there are resources, the question is how well people are using them and whether we have enough time really outside of work to kind of focus on that mental aspect.

Gideon Lichfield: Right. I know that there was at least a point, I don't know if it's still the case, when hospitals were not testing their healthcare workers unless they were really, really sick for coronavirus because then there was the problem that you wouldn't test positive then you get furloughed for 14 days, but the hospital needs you. Is that still going on and what effect is that having?

Craig Spencer: Yeah. So it's still, it's gotten much better. But it's still not basically on demand testing for employees. Again, I know a little bit more about my institution than other institutions, but talking to friends around the city, some places are a lot better. Some places it's still a challenge. Really with the testing focus is trending towards now is looking at immunoglobulin. So for providers to see those who have been exposed, whether they were symptomatic or not, to see if they have immunity. The goal being if we know someone has a strong immune response, their likelihood of being reinfected in the near future, it is extremely low. And so how can we better prioritize putting them on the frontline, taking care of the more at risk patients so that it doesn't expose others like myself or my colleagues who haven't yet been infected, decrease their risk so we can have more health care providers, really at all times in the frontline. That's something that we're focusing a lot more on that universities and you know, virology labs had been stepping up and we're seeing a lot more of that coming out in the past few days. And certainly more so over the next couple of weeks.

Gideon Lichfield: And is there any information on what proportion of the healthcare workers in New York have been infected so far?

Craig Spencer: Not, yet. Not for New York city. I mean we know it's a huge number. Thousands of healthcare workers in China were infected despite you know seeing the personal protective equipment, it was pretty intense and a lot of places. 8% of Italy's infections were healthcare workers. I saw a pretty massive statistic in Spain that, you know, with a big percentage of their infections were healthcare workers. We don't know. I have colleagues that have already been affected. I have a bunch of colleagues that have already been infected that I've tested positive, some that have documented immunity, we don't know. But I would not be surprised with kind of the missteps and preparedness, the lack of PPE, really the kind of, the lack of urgency initially and early on. As well as the fact that this virus was spreading here in New York City much earlier than we thought, I wouldn't be surprised if a good chunk of my colleagues, were positive or had been positive.

Gideon Lichfield: And when people have tested positive and then they recovered, are they presumed to be immune and do they, does that change the role that they perform in the hospital because they're now seen as less susceptible?

Craig Spencer: Yeah, we're just starting really to see that. Again, we're getting this antibody testing online. So I have one of my friends who was tested a couple of days ago found to have a good serological response, meaning that she's immune, she has antibodies that should protect her for the near future. We don't know how long. So that's just starting to happen. We will, I think everyone is thinking about how do we do that? How do we better deploy those people with documented immunity, not just in the hospital but in grocery stores and in all parts of the economy. Is there a way that we can kind of use these superheroes with their super antibodies that have this lower risk of being reinfected and less likely to spread the infection to others? How can we use them in a way to start opening up a bit on some of the normal functions of our daily life.

Gideon Lichfield: Alright. So for those of you who are watching, just a reminder, I'm talking to Craig Spencer and you can submit questions in the comments on Facebook and YouTube and I will see them and put them to him. Craig, you talked just now about ventilators and about the fact that a very high proportion of people who get put on a ventilator don't make it. And I've seen some reports recently that there's some rethinking going on about whether everybody should be ventilated about whether or not it's actually helping. What's, what are you yeah, what are you saying about that?

Craig Spencer: Yeah, I've been keeping up on that in the past couple of days as well because we're, the challenges that what we're seeing, it's different than what we've ever really seen. We're seeing patients that come in that may not necessarily look that bad, may look sick, but not like they need to be intubated, but whose oxygen levels are in the 40, 50, 60%, which is unthinkable. If I ever saw anyone who's oxygen was that low in normal life, I would absolutely double check that that's the right reading. And if that was a case, intubate them because it's the only way that we're going to, you're going to save lives. What we're seeing now is that there's this disconnect as part of the disease process in between people's presentations and their oxygen saturations for a lot of people who come in in distress and respiratory distress or are not breathing, they need to be intubated, otherwise there's really no other option. But we're starting to rethink which of those borderline patients can we maybe be a bit more aggressive with noninvasive, modalities. So like that CPAP mask that people wear to bed at night. Can we try that? We haven't really done that much up until now because it's an aerosolizing procedure, meaning that it can take some of the virus and it can spread it out into a pretty big space, increase the risk to health care providers. Also increasing face mask, oxygen, nasal Canyon, oxygen. We're gonna see how this changes over the next couple of days, the next couple of weeks, but it's a different disease process than anything we're used to and that's causing us to rethink about how we respond both from an emergency perspective but also from this kind of longer term intensive care perspective.

Gideon Lichfield: Right. I mean, I've seen pictures of in France and Spain for instance, doctors putting snorkeling masks on people and having a kind of ventilator bag that way. But are you resorting to any of those kinds of measures or do you have that equipment at the moment?

Craig Spencer: No. Yeah, we haven't really been forced to improvise too much. We've had access to ventilators, the noninvasive to all those modalities. Really the question is like, if we have the supplies out, what's the best thing? What's going to save the most lives and decrease the amount of complications not only for patients but also for providers. And the one thing that's really hard for a lot of people to recognize in this scenario is that in a pandemic, you know, the, your priorities get shifted around step one are really, your first priority is going to have to be protection of your healthcare providers. Without us on the frontlines, there's no one to take care of patients. And step two really has to be providing the highest clinical care that you can, while providers are safe. So this is a bit of a shift. More of a shift than many of us recognize and I think it's forcing us all to kind of rethink about our jobs our duties our obligations. And also them modalities that we use to save people's lives if they're going to be a big risk to healthcare providers.

Gideon Lichfield: Right. One of the people watching has asked what your experiences of telling you about the spread of the virus in the city. In other words, how widespread do you think the virus is compared with the numbers of people that are actually testing positive?

Craig Spencer: Right. I'll put it this way. I can work a shift. If I'm working one of our lower acuity areas, I'm meaning, where know it's not the place that we're going to likely be intubating patients. If I'm working in a lower acuity area, I might see dozens of patients during a shift, many if not all of them with symptoms of covid because they're being discharged home. They're not tested. And this is true across the city. That means that I can see in many of my colleagues in the span of one shift could see tens or dozens of patients that are all COVID positive, that are never tested and never included in the case count. So I think what we can say is that this virus was spreading in the community well before we recognized it. I think our first case here in New York city was March 1st we likely had transmission for many, many weeks before that. Looking back, it's kind of clear that there were some patients that were a little bit different that maybe we didn't pick up.

And I think that right now the testing that we're doing is certainly not comprehensive. We're not getting a big chunk of the infections. We're really getting the sickest people, those that are getting admitted or the health care workers that are getting tested. We're probably also not picking up the true number of deaths. There are people dying at home because they're not coming to hospitals. Chest pain is basically nonexistent, you know, cardiac patients, those with acute heart attacks. I'm not really seeing nearly as much as we were before. Surgical abdomens people with appendicitis, gallbladders, all that kind of stuff. We're just not seeing. So what's happening? People are not choosing to not have these acute health crises. You're probably managing them at home with fatal complications for some of them, undoubtedly.

Gideon Lichfield: Right. One of the things that people are talking about now is the signs that it seems as if the curve in New York or the peak of infections might be, might be approaching or might or have already arrived. What do you think of that?

Craig Spencer: That'd be great. We don't know. Look, we can look at trends. I'm trained as a field epidemiologist. I love data. Models are really great. Some of them are not. We don't really know. Look this last weekend, I think it was on Saturday or Sunday, there was a lot of, you know, kind of positive enthusiasm that the number of deaths from Friday had dipped on Saturday and then dipped again. Maybe just by a few, but it was, it was really emblematic of maybe things are changing, maybe this is turning the tide and then again on Monday, I think the deaths were record high. I think we're gonna need to see how this happens over four or five days to start looking at some trends. We don't know, again, variable presentations, testing, deaths. Our data is not perfect. It is suggestive. And maybe we're at that point where we're flattening this curve. My concern is that people will think of this as reassuring and in a sense it is, it's reassuring that we're not continuing to do this huge spike up.

But if we flatten the curve, we can travel along that crest for weeks, you know, for days, maybe many weeks. And each one of those days is a huge number of deaths, a huge number of people in our ICU and in our ERs. And what we're doing dealing with now is that we already have backlogs, right? Covid patients take a really long time to get better if they get better. This is not a three day disease, this is a two week disease. So think about all the big backlog we've had in the past couple of weeks. We already have ERs and ICU's full. We don't have a lot of place to put more people. Ships and tent cities and central park, ect are great if we have the right capacity. But even at that plateau, it's still really, really dangerous. It's still a huge amount of work for healthcare providers and there's still a huge risk for patients and there's a really big risk that if we let up, as opposed to doubling down and stepping on the gas with social distancing, physical distancing, staying at home, we risk having this really big rebound again in a week or two.

Gideon Lichfield: Right. And I think I saw you say on Twitter that this plateau that we appear to be reaching might not be because the number of cases, the number of people getting sick is leveling off, but simply because the capacity of the hospitals has been reached.

Craig Spencer: Yeah, I mean we are quite honestly discharging patients that could have been considered for ICU admission. And this is not. All over the city we have protocols that say, you know, if your oxygen saturation is 90% or above, if you're walking like you go home 90 or that in the past that people that need oxygen, we would have absolutely admitted them to the hospital, maybe giving them a higher level of care and observation. Now we're sending people home with oxygen concentrators and pulse oximeters, to kinda monitor those themselves at home. So yeah, the rate of admissions is decreasing and we actually see some of that to be true. But it may be that we're using different criteria. So we're comparing what's happening now versus a week ago versus two weeks ago. And they're really non-comparable measures. So it's reassuring. And again, I think the data is pointing towards some type of plateau. Great. I mean it doesn't mean that we can let up and it doesn't mean that things are actually much better off.

Gideon Lichfield: Right. Someone is asking a question. Well the question is what PPE shortages have you experienced that are not being reported in the media. I would guess that most of them have been reported, but is there anything in particular that is sort of maybe you think people are not aware of and other, any creative solutions that actually work pretty well?

Craig Spencer: Yeah, so what we are reporting on is really like our plan C just like our, you know, our plan A for testing should have been, we should have had a test ready and then plan B was okay we didn't have one ready but we rolled one out as imperfect and we should have improved it. Now our plan C is like, okay, we're only testing certain people because we have limited testing. The same is kind of true for our PPE. We have, the supplies that we need to do what's being recommended non, but what's being recommended is not necessarily our plan. What should be plan A, the CDC says that you should not be reusing masks in the way that they're being reused. So yeah, we have PPE shortages based on an ideal, even if we have an increasing number now and I have PP and many of my colleagues have PPN work, it might not be the ideal scenario.

So in terms of some of the creative solutions, yeah, we've, we've had a lot of people that have reached out about 3D printing masks, face shields, which has as actually really helped, we get deliveries of these all the time. And I know other hospitals too. People printing out these kind of just clear face shields that we can strap up with a band that gives us some protection for our face, prevents any type of virus from entering our eyes and in our mouth or onto our masks. You know, kind of coming down to here and people have been churning those out at a really rapid clip. So we have a good number of those, thankfully.

Gideon Lichfield: Right. If people want to donate, what should they donate? Where to?

Craig Spencer: Yeah, that's tough cause I get emails all the time. Hey, I tried contacting the hospital and I've got 15 N95s that I used for woodshop a couple years ago.You know, that's great and we want people to do that. It's just really, really, really hard. Each hospital has a procurement team and generally each hospital or hospital system or even cities will have something up, a website that says, Hey, are you looking to donate things? Reach out here. Even then though, I'll be quite honest, it's been tough for even for bigger companies and big organizations that have hundreds of thousands of masks to get to the right people to donate things for whatever reason. I think a lot of these teams are, are overwhelmed. There has been a huge outpouring of support, which is great.

What I would probably say is if you have things that you want to donate either in time or in terms of supplies, it's probably worth reaching out to some of the underrepresented or really under-supported institutions, so a lot of city hospitals for example, might not have the same access to supplies as a lot of your bigger name Ivy league institutions. So that might be another good place to start. A lot of the people on the front lines and those places are dealing with a bigger case count and maybe some less resources. And again, this is kind of variable all throughout New York and likely will be variable all throughout the country. I think of the case, think of the places that are generally underrepresented and already marginalized at baseline, those are probably the places I need more of your assistance right now.

Gideon Lichfield: Right. Someone else is asking how often a protocol is changing, I guess that's protocol.

Craig Spencer: Every day.

Gideon Lichfield: ...treatment. How do you keep up with it and stay coordinated? How do you make sure everybody's following the same protocols?

Craig Spencer: It's really hard. Literally every day there's a different type of protocol for something for involvement in palliative care or for certain PPE during procedures or for yachts. It's nearly every day I'll get some type of email or some type of message about how this is changing. We just need to be on top of it. It's a challenge because we're learning so much about this disease as we take care of it. Hospitals themselves are responding to how we're managing this disease and what resources they have or human resources, financial, supply. So it just, it's sometimes feels like another job on top of a full time job of just being aware of what's happening, reading and knowing what's happening in our departments, in our hospitals.

Gideon Lichfield: Right. I think a lot of people are curious about whether any of the medications that have been touted at the moment that are, some of which are in trials, have any effect. What kind of experience have you got of that?

Craig Spencer: We'd all like to know, like, I mean, the thing that I tell people is that we all want, this is this is politics aside. This is from a public health standpoint. We all want to know if any of these medications are instead of VA or hydroxy chloroquine. Is it Azithromyson? Like I would love if any of them were a magic bullet. The thing is that we just don't know, and there's always a downside of using a bunch of medications that do not have proven efficacy. Sometimes we're forced to do that, and I was treated for Ebola, I got Princeotnzophrovere which was an experimental medication for this. I got plasma from a survivor. We now know retrospectively, looking at the data that neither of those helped in my case, probably made me worse. Does that mean that we shouldn't have tried them? Maybe. Maybe not. We didn't know at that time. Maybe they could have been helpful. The question is right now we're talking about this really kind of large mass drug administration for these patients, not knowing how these interact with people's underlying medications, their comorbidities, and even the disease state. As of right now, the only thing that we know that has a profound and rigorous evidence-based, it's known to decrease mortality is staying home, all the other medications may be effective. Again, I hope that that's the case. I hope if we give hydroxychloroquine to people, it kills Corona virus, inside too, like on the spot. We just don't know that. And so I think it's dangerous for us to say, well, what's there to lose with there to lose is a, each of these medications have side effects. The cure could be worse than the disease

Gideon Lichfield: When...to quote a famous person...when the curve eventually starts to fall in New York City, I know one of the things that's going to happen is people are going to say, Oh wow, it's getting safer now and will want to go out. And they won't want to stay at home as much. But what do you think? I mean, what is going to have to happen then? Because if we don't have a vaccine at that point, which won't, and if we don't have a treatment, then is there any alternative to people just kind of staying at home until, until we do? Do you see a way that people start to come out again?

Craig Spencer: I think, yeah, I think a lot of this is gonna depend on how well we can get antibody testing up this immunoglobulin testing. If we know that 20, 30, 40, even more percentage of the population has already been infected and has some type of immunity, we probably want to start there. We need to think about it kind of our high hit, economy. You know, getting those things back up. Initially I know that the governor here and then in the surrounding States, they've already started thinking about kind of the business plan for how we reopen. And hopefully that happens sometime soon. I totally understand the economic impact. Today I was talking to someone who hasn't had a gig in five weeks as a photographer making no money, under the impact this has on, you know, people that are doing cleaning services here in the city generally from the from the already marginalized either undocumented communities or from the Latino community here which are showing a double, doubling of the death rate, for those ethnic groups when compared to white New Yorkers. So people are already kind of going out and doing things because they have to. I'm just concerned that once people start thinking it's a little bit more safe, it's going to increase. We're going to have this increase in spread and it's going to put more people at risk. There needs to be this thoughtful plan of how we slowly open things up to decrease that risk. Understanding that again, transmission will likely probably pick back up.

Gideon Lichfield: Let's talk a little bit about that, what you just mentioned that the disparity between how this is affecting people of different ethnic groups. Why is that happening?

Craig Spencer: What I've been saying is that coronavirus is amplifying the inequalities that have existed not only in New York City, but in the US for hundreds of years from even before our founding. You think about the communities that have already been marginalized and are already vulnerable before coronavirus, undocumented communities, indigenous communities, those living in areas with higher air pollution. We know that their health outcomes are worse. Their likelihood of dying at a younger age is much higher likely of having chronic diseases and, are higher access to healthcare is limited. We're just seeing that amplified at full speed here with coronavirus. So yesterday we got dis-aggregated data on death by ethnicity here in New York City and it wasn't super surprising, but it was absolutely stunning. So the rates for, black New Yorkers, African-American New Yorkers was nearly double that of white New Yorkers. And the rate for the Latino Hispanic population here was more than double, which is just astronomical.

Gideon Lichfield: The infection rate or the death rate?

Craig Spencer: Yeah. Basically the likelihood of dying. Yeah.

Gideon Lichfield: The likelihood of dying if you catch the disease is double.

Craig Spencer: Per yeah. Per a certain, a number of population for a set denominator. Absolutely. Yeah. Basically what it just means is that more black New Yorkers, more people of color here in New York City are being infected and are dying from this as opposed to people like myself or my friends that are, that have the financial means to stay at home that maybe have a job that they can do from zoom as opposed to in someone else's apartment. And I mean we're just seeing that amplified and it's, it's really sad and it's astonishing. But at the same time, this is the reality of not only New York City but the rest of the country, this is the inequality that has existed and we're just seeing it and the catastrophic consequences of it here in full view.

Gideon Lichfield: Right. When you look at what, how other countries have dealt with this, and I don't know how much you've been looking at other countries, but what do you think are the lessons that we should be taking?

Craig Spencer: I think the biggest lesson is we should've listened a lot earlier when China tried to warn us when Italy tried to warn us. It's so funny cause when I say that I get so much pushback every time I say China tried to warn us, I get a handful of emails from people saying, well no they didn't. And I don't know what else China needed to do to warn us about a global pandemic. Then basically sending us videos and showing these images of people dying in the streets and overcrowded hospitals. Like if we weren't warned by that and prepared by that, well that's our own damn fault to be honest with you.

Like we knew this was coming. We knew the infectious capability of this and we also, people like myself knew the pandemic preparedness infrastructure had been torn apart in the past couple of years here in the United States. We've underfunded our institutions responsible for preparing. We've ended programs like predict, which was a USAID supported program meant to find the zoonotic diseases. You know, those diseases as viruses and bugs that spring from animal vectors all over the world. That ended not that long ago before this pandemic started. Like in a sense we learned some lessons from West Africa in Ebola and then years after that we just kind of let them go by the wayside. And so we were warned. We knew this was going to be bad. We saw in Italy, I think some people maybe undermined or undervalued the impact it was having there. Lombardi, the region in Italy where that was impacted is one of the wealthiest areas in the world and some of the best healthcare structures in the world. And we're just completely inundated.

So remember that when this was happening, still no one really taking this serious here down, downplaying the impacts and we only have a certain number of cases and it's all going to be under control. Like it's super dangerous and the result is we're seeing the consequences right now. We weren't prepared. We took apart the pandemic preparedness infrastructure and ongoing, our preparedness has not been really anywhere near to at the rate of the curve or in front of the curve. We've been weeks behind it and we're seeing it in New York, thankfully, and hopefully other places throughout the country that will see this come over the next couple of weeks. Next couple of months are learning from our mistakes and starting to better prepare. But yeah I only hope that's true.

Gideon Lichfield: You know, my takeaway from it is that it sort of it has to get personal in order for it to get real and you can see it happening across the world, but you don't, you don't think it's going to happen to you somehow. I mean, for you, when was the moment when you realized that this was going to hit the US the way it was hitting elsewhere?

Craig Spencer: As soon as I saw it in China, I lived in China in 2006, 2007. I lived in a small city of 4 million people. And I remember walking by the bird market every single day thinking like, man, this is where it comes from. Like this is where the pandemic starts. And we know that the Sunata diseases from wet markets and it's not just a China thing, it's everywhere in the world thing. Like then the next big disease is not going to come likely from Missouri. It's going to come from Northern CAR or China or somewhere else. But it has the opportunity and the ability to spread around the world within 24 to 48 hours. I think people like myself that have been worrying about this for years knew really early on and this was taking down China, that this was going to have a huge impact elsewhere in the world. We were trying to raise the alarm and raise a flag and let people know what was going on. But I think the public health messaging was being undermined and covered up by the political messaging, which is unfortunate.

Gideon Lichfield: Yeah. Talking about messaging, what do you think is the right way to do that? Because aside from the fact that it's become very politicized in this country, you also have really mixed messaging coming from a lot of different experts, so it seems. I mean there are many, there are many different epidemiological models. They vary in their projections. There's debates about masks, you know, so how, and then, you know, we have the media organizations like ours which are trying to pile in and provide stuff as well, but we're also creating a cacophony. How do you think we get… What would be the right way to get more consistent messaging that everybody could be aligned on?

Craig Spencer: I think we amplify public health voices over the political and we do that by letting public health professionals speak. They should be the ones at the podium. I know that that's clear and that makes sense and that's not what's happening. I think the other time we as public health professionals need to be honest about our messaging and think about all the consequences that we know could happen. You know, my concern is that we're flattening the curve and we're going to do this all over the country and maybe the projections are not going to be, or the desk counts are not going to be as bad as some of the worst case projection models. And people are going to say, well, the modelers were wrong. Undermining the value of public health, kind of epidemiological modeling. Or they're going to say, you know, we the media, stoke this fear about, you know, a million people dying and only a hundred thousand people died or so the whole time we should've been saying like, look, if we do this really well, we won't hit these models.

Craig Spencer: Like we will do much better than this. This is a worst case scenario. We were doing that to get people to act, not thinking in the longterm of how it can undermine public health credibility in the future. So I think that could potentially be used against us. I think that could be used by politicians that undermine our expertise and we just need to get more public health professionals in of the camera talking to reporters. They're doing the science and sharing in a way that is easily understandable, digestible, but also honest and transparent. And that's, I think, a big challenge for all of us.

Gideon Lichfield: Yeah. One of the things that has struck us, I mean me and my colleagues is, you know, for the last two or three weeks, we've tried to get a lot of doctors and nurses and public health workers on this show to talk to us about the situation in the hospitals. And almost universally they've initially said, yeah, I'd love to come. And then they call back and say, actually, my hospital told me I can't do it. I'll lose my job. So A) how come you're speaking and why? B) why do you think some many hospitals are reluctant to let their healthcare workers speak? Cause I would've thought that they all share an interest in these messages out.

Craig Spencer: Yeah. I think what's been a challenge for a lot of hospitals all throughout the country is that kind of what we're dealing with and what we're seeing is so unlike anything that we're used to. And I think a lot of us are processing this externally. In a way that may sound really bad in may, yeah, may not necessarily reflect on the institution, which may reflect more on the actual reality of what we're dealing with the in a lack of PPE, be it a lack of, um, supplies. But I think with the way that healthcare has become, quite frankly, a business, a huge business here in the United States, a lot of the focus has been on how do we protect the business? Well, at the same time trying to provide a really high quality health care. And unfortunately frontline providers just sharing the reality of what they're seeing may be too stark a reality for much of the general public.

I get requests all the time, all the time from reporters to have a look inside the house hospital to shoot video clips. And outside of that being, you know, unnecessarily for your realistic. I think it also just highlights that people want to know what's happening. But at the same time, hospitals not wanting necessarily to show that because in many places it is, it's unlike anything that many of us have ever seen, and it's not an image that a lot of institutions want to be sharing with the general public because it doesn't fit with this idea of who we are and who many of them are as institutions. Which I think is a little bit unfortunate because I think it undermines the really important flexibility, adaptability and the capacity that we have to respond to this. I think that, hospitals, you know, friends at different hospitals have shared these concerns with me, I think that asks us, has gotten worse. A lot of places I've recognized that's important to have people on the front lines stepping up and talking and chatting about the reality because the messaging, it's not clear. The public health and the frontline messaging, it's getting contradicted or mixed with the political messaging. So I think there has been a bit of a change. But you're right that there has been a lot of reluctance and having frontline providers speak for a bunch of different reasons.

Gideon Lichfield: Right. Some people are asking about, you know, some of the basic precautions aside from staying home, which is obviously the most important one, people are asking things like, you know, does, does vitamin C make you more or less vulnerable for instance, to getting infected. Are there any other besides thing, or any other recommendations you have for people?

Craig Spencer: I mean specifically the vitamin C, there was one protocol that was put out talking about, IB methyl Prednisilone, a steroid and an antibiotic and vitamin C. again, we don't know, we don't know the reproducibility of these and whether this is actually true, whether is this generalizable to all patients or a certain subset, we don't know. Again, we hope that that should be true. If it was as simple as taking a vitamin C every single day and that prevented you from infection or treating infection, that would be great. We could scale that up quick, but we don't know. In terms of the other things, obviously, you know, the same boring messages are boring. Washing your hands in a really good way is really boring, but that is the best way to protect yourself from coronavirus and every other infection. Wearing a mask when you go out is huge, but not just wearing it, wearing it correctly. The majority of the time I see people wearing a mask incorrectly. It doesn't cover your nose, it isn't working. If it's hanging underneath your chin, obviously it's not working. If you're touching it to take it off like this, moving things around, you're just potentially infecting yourself. I think people are are hearing these messages, wash your hands, stay at home, use a mask. This is all great, but our actual operationalizing of it and the way that we actually implement these suggestions is not good. I would prefer instead of us looking for these magic bullet medications for us to focus on the things that we actually know, decrease mortality, decrease transmission, and that is saying home as much as we can using mask and using it correctly every time that you go out and washing your hands. If we do that, it will have much bigger impact than anything else that we could do.

Gideon Lichfield: So you think we need even more messaging on this? Like from the government official, official messaging, I don't know. Posters everywhere, that kind of thing.

Craig Spencer: Yeah, I this is not just an indictment of the public and how people are using masks, although it's certainly the case. I see people on the street, like this is true in hospitals too. Every single day I give feedback to a colleague about their PPE, Hey, I can, you know, see this gap here. Or Hey, your mask isn't covering this part of your face. Or Hey, there's this area under your goggles. It's like, it's not, it's just that we as humans are imperfect and even the most perfectly, even the most perfect mask used perfectly is not perfect. For a lot of people, it changes their behavior. It makes them get closer than six feet because they think they're protected or do things that the otherwise wouldn't. So I think that, yeah, we just need to focus on the essentials and I know it's boring and it's hard to get people to listen, but like people are inside all day watching TV like this is our time. Either hit 'em there or hit 'em on Twitter or wherever we can. I just think you hit those messages and make sure people know how we're washing our hands well, how we're using our masks correctly and what social distancing actually means. It doesn't mean having a barbecue in the park, wearing gloves, talking to your friends who are three feet away from you, which is a lot of what I see.

Gideon Lichfield: I'm going to wrap up soon, but I have one more question from someone watching, which is about the use of technology to do contact tracing to identify people who have been close to someone who's exposed. So obviously in places like Singapore and South Korea and Taiwan, they've been using various kinds of automated contact tracing where maybe you have a smartphone app and it identifies you, you've been close to and it sends messages to them that you know, this person has been infected. In San Francisco, they are now starting on a much more manual form of contact tracing where if somebody is tests positive, then they interview them and they try to trace their movements and then connect with the people that they've been in touch with. So it doesn't have the kind of technological surveillance aspect, but it's a lot more work. What's your view on like the right way to do contact tracing? Do we need these kinds of automated systems and then what are the privacy implications if we have that?

Craig Spencer: That's a great question. Contact tracing is bread and butter public health contact trace task tree you want and you try to isolate cases. It's a little tougher with coronavirus because we know asymptomatic or pre-symptomatic transmission being that people without symptoms can be transmitting this disease. With Ebola it was really easy, right? Like, if you have Ebola, you have a fever at some point when you're infectious. So contact tracing then was really easy. Go check people's temperature twice a day. If they have a fever, they're a person under investigation. With coronavirus, it's hard. A lot of younger people may get no symptoms at all and maybe infectious. You can do, and I think that there should be a role of contact tracing, especially in certain communities. Where it's possible. I mean, it involves a lot of work as you alluded to, having someone follow the movements of one person over the past couple of days, it's actually quite a bit in normal times, you know, where you go, where you buy things, where you eat, who you interact with. Potentially, it could be dozens or hundreds of people. There certainly is a role and if you look at South Korea's experience with contact tracing using electronic means and the same in China, it works.

The question is that something that our culture and our society would accept? Generally, I probably would have been before all of this, I probably would have said no, but I also would have thought that if you asked all of us to stay at home for the span of many weeks, despite the economic implications, I don't think that we would have done that either. And surprisingly like people have really taken to that as much as they can. So I think people just want to know where the other side of this is and get there as quick as possible. And if that means that it follows your phone, I would be surprise if the uptake wasn't higher than I initially would have imagined. Yeah. I mean, quite frankly, our phones are already being followed, so.

Gideon Lichfield: Right, right. I suspect that people will be more willing to give up that kind of data in return for some freedom.

Craig Spencer: Okay. Yeah. After having, after having lived in, in China for quite some time, like it was so interesting the difference between the micro freedoms and the macro freedoms. Like, you know, in China you have a lot of micro freedoms. You can drink a beer on the street, you can do all these other things, but it's a macro freedoms that are more repressive. Here in the US it's the inverse, right? We have all the macro freedoms, we can vote for whomever we want, we can talk about, you know, freedom of speech, etcetera. But it's those micro freedoms. Can't drink a beer on the street, there's some other things that we don't necessarily have. So I think that kind of, that cultural difference is one of those maybe barriers or us being okay with the government finding us and following us around on our phones, knowing if we've interacted with certain people and alerting them via text message. But again, I think we've slowly and gradually, already given into that in some sense. And I just wonder how many people would be okay with us extending it a bit more for a temporary period if we know that it would have an impact on living and transmission of this virus.

Gideon Lichfield: All right, well we're gonna wrap it up there. Is there any other thing that you want to say? Any message you want to pass on?

Craig Spencer: Yeah, I think the important message is, is that we talk about this, it's such, it's such an inwardly focused discussion around what's happening, not just, you know, in New York City where it's bad, but I keep hearing this talk about the 50 States and hardly anyone is talking about the impact this is going to have on places like Guam or Puerto Rico. Puerto Rico has one of the highest percentage of elderly, in the country has a higher population than 21 States, has a weaker healthcare infrastructure and is still rebuilding after Maria. Like, when you think not only about the impacts this is going to have on our local communities, but on other American communities, not just the ones that we think about in the continental US and this disease is undoubtedly going to hit Mozambique harder then it will Missouri. And so even if we don't necessarily, you know, have boots on the ground response, I think starting with empathizing and thinking about people outside of our own borders is a really good start to recognizing that this is a time of important global solidarity. Everyone is dealing with this virus regardless of the color of your skin, the size of your pocket book or where your passport is from. I just want people to recognize and take a moment because that's never really part of the conversation.

Gideon Lichfield: Right. And that's also not an entirely selfless thought, is it? Because as this virus spreads through, particularly through cities with large slums in Africa, it's going to go, it's going to spread like wildfire. And then you have the, you know, the kind of very much more widespread in the rest of the world and that that also has an impact on countries that are other countries that are trying to fight it.

Craig Spencer: Yeah. It has impact on all of us. Yeah, for sure.

Gideon Lichfield: All right. Well, Craig Spencer, thank you very, very much for spending the time with us. Thank you for the work you're doing. Warm wishes to all of you and all of your colleagues out there. Thank you.

Craig Spencer: Excellent. Thank you. Thanks for tuning in everyone. Bye. Bye.