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In a series of recent messages, Dr. Joshua White has echoed the advice of state health officials: don’t panic about the coronavirus, exercise proper hygiene and use social distancing to slow the spread of the disease. But White, who is the chief medical officer at Gifford Health Care in Randolph, has also been blunt about what probably happens next.
“It’s highly likely we will all get coronavirus sooner or later,” White wrote last week. “Two weeks from now, there will likely be hundreds of identified cases in our communities,” his latest message reads.
Why? White believes that the broader context around this outbreak will help Vermonters understand it better — and take proactive steps to help more vulnerable members of their communities.
“When you hear stories of crises in the past, it is people thinking clearly, solving problems and working together,” White said in an interview this week. “That doesn’t mean bad things don’t happen. It just means that they’re handled intentionally and not in a reactionary fashion.”
On this week’s podcast, White discusses what to expect from the outbreak — and how to keep calm as the numbers rise.
**Podcast transcript**
Could you just say your name and your role here?
Josh White, and I am the Chief Medical Officer here at Gifford Medical Center and Health Care.
What does that mean exactly? What does a chief medical officer do?
White: You know, two years ago I would not have been able to answer that question myself. I am responsible for basically the medical activities that occur in both the hospital and the clinics. So oversight of everything from hiring doctors and nurse practitioners, to the care they deliver, to quality measures, and, you know, how are we doing with our colonoscopies, to complaints. And everything in between.
So you’re the top doctor.
White: Kind of, yeah, that would be one way to think about it.
There’s a lot of doctors in Vermont, a lot of medical officials. Not all of them are doing what you’re doing, in writing these messages to the community and talking to people about how to conceptualize this virus. What compelled you to do this in the first place?
White: I guess there’s two parts of it. One is that I actually have a background of — a formal former medical school classmate and I ran a field hospital in Haiti after the earthquake. And so there is some background in — I don’t know if you’d call this a disaster, but in big public health situations where there is not a clear plan, and you have to figure things out on the fly. Such as, you know, with a novel virus that humanity has not experienced before. In that case, it was different, but managing it from a system approach, with many, many people interacting with that system, and their behavior, has informed a lot of what I’m doing right now.
At the same time, institutionally, right now our biggest threat is a public panic. Like, any given business or operation or a factory, there is a process by which you do things. And if you overload that system, it will slow to a stop and become nonfunctional. And so what we’re considering right now is, how do we handle this? And a lot of medical systems are actually fairly fragile.
A great example is if you consider an emergency department, the average emergency department. If you were to go in there right now, with no complaints, and the only thing you were to do is ask: I want to be tested for coronavirus. And all they said to you was, no, it’s not appropriate. We can’t do that right now. And you left. That would take 20 minutes of processing. A dozen people arriving in our emergency department all at once with that request would slow the system to a stop.
At the same time, people are not going to stop having heart attacks, they’re not going to stop hitting their heads. People are going to continue to require medical care. And so in thinking about the processes we have and caring for the people in this community, it quickly became apparent that we had to get control of the dialogue and not let, you know, entities that are surviving on clickbait or fear drive that behavior. And so this, in large part, I see it as a service to our patients. This is a service to the guy that is going to have a heart attack tomorrow. He can’t have 30 worried well in the lobby of our waiting room, or he’s not going to do as well.
Sure. I imagine media is only one part of this though. What are other ways that you can stem the risk of a panic taking hold here?
White: Well, a lot of it is just people — when people understand what the situation is, when they have information in front of them that they trust, and they understand the logic behind requests or directives, they tend to do better.
This is a scary thing. You know, we’re talking about a virus that came from a different country that people haven’t experienced before. And we’re talking about people dying. We’re looking at a stock market crash. It’s normal and appropriate for people to be anxious and afraid. And so subsequently, you need to provide them with some sort of structure to contextualize their own behavior.
“What’s going to happen next?” is a natural question. And so the impetus is on us to try to answer that question and tell people what we know, how they can contribute, how they can protect themselves. And we’re relying on our own staff and the community for a lot of this.
Right now, this week, in particular, it seems like we’re in the middle of this cascade of information about things like school closures, event cancellations, that sort of thing. And even though this is in line, more or less, with what health officials have said all along is what was likely to happen, it still feels like a little bit of a reality check in terms of how this is going to affect people’s day to day lives. How should people be absorbing that information?
White: That’s a tough one. And our strategy thus far has been constant communication, constant reassurance. Overall context is really, really important. I’ve written about things like relative risk. It’s very easy to read a post by an epidemiologist that says, you know, worldwide there’s going to be so many million deaths. And it’s very easy to get anxious about that. But people need to remember the contexts in which they exist. In terms of this virus, if you’re 29 years old and you’re healthy, your individual individual risk is very low. And you can’t forget the reality that that person’s talking about, when an epidemiologist writes an article, is not necessarily your reality in the moment.
You also can’t forget that you exist within a community. And when we’re looking at the panic behaviors that are getting reported all over — the buy-ups of supplies, the stealing of masks, people wearing masks in public — it’s really, really important to remember that you never hear stories, and you never hear recounts, of “everyone for themselves, everyone freaked out,” and a good outcome. Because that’s not how it works.
When you hear stories of crises in the past, it is people thinking clearly, solving problems and working together. And that doesn’t mean bad things don’t happen. It just means that they’re handled intentionally and not in a reactionary fashion.
It seems like there’s a balance to be struck here. Because particularly this week, again, as people are getting all these announcements coming down, it does increasingly feel like there’s a sense of high alert from a lot of our institutions. How should folks balance this sense of alert, this kind of goal of social distancing to slow any potential spread of the virus, with this idea that we should be kind of checking ourselves against what our individual risk is?
White: Sure. So there are individuals for whom this is very high risk. And there are situations that keep me up at night. A simple example is, you know, Gifford manages a retirement community, and we have a nursing home. What happens if and when this virus gets into that nursing home? And that’s a big deal. As you may have read about in Washington, that kind of thing is a catastrophe.
When we’re talking about things like social distancing, those are strategies that are important and to be applauded, because those will slow the spread of the virus. If you are healthy, but infected, and feeling fine, you not interacting with other people is going to slow this virus down. If everybody does that, and we do things like cancel large events and we slow this virus down, it is going to take a longer time for that virus to reach Gifford’s nursing home. That period of time is critical to saving lives.
There’s a concept — if you imagine a given health care system or a part of the health care system has a certain capacity. There are certain number of hospital beds, or a certain number of ER beds, or a certain number of patients we can process in any time. If we slow this virus down, the surge of patients that we’ll see will flatten. And it is less likely to extend beyond that capacity and for a shorter time period, and that’s going to save lives.
This is what people talk about when they use the term “flattening the curve.”
White: Correct. At the same time, you don’t want to be alarmist. If you’re planning on a concert and it got canceled, you need to understand that that is a good thing for a lot of people. And in this community, there are a lot of elderly people, and I’m worried for them. I’m worried about how we’re going to take care of them. And if collectively as a community we can flatten that curve, they’re gonna do better.
What are your worries?
White: The capacity thing. As a product of our hospital’s critical access designation, we’re currently at 25 beds, 25 inpatients that we manage. In emergency situations, we are allowed to extend beyond that. But that’s not what we normally do. And so if we have 40 beds that are full of sick people, I don’t have the normal medical staff to manage that. I don’t have the nurses for that. You know, if the schools close nationwide — 38% of nurses have kids that are school age. What are they going to do when I need them? And so these are the conversations that we’re having. How do we deal with that? And we’re putting together plans to deal with that. But the public can make it easier by giving us more time and flattening the curve.
I’m curious if there are specific lessons from the work that you were talking about earlier that you’ve done in Haiti, that would be applied to a situation like the one that we are looking at here.
White: A lot of it is logistics. A lot of it is creative thinking and problem solving. An example might be that if we have to extend beyond our normal capacity, are we going to do things like close half of a clinic elsewhere and bring that staff here and have them perform other jobs? So your primary care physician may serve as a hospitalist, here in the hospital, taking care of people with this illness. If we reach that need.
That was the same kind of thing that we ran into in Haiti, where you’re faced with a situation where there’s not a clear answer. You don’t have the normal supplies for that. And so you figure it out. You can’t be paralyzed with indecision because the downside to not figuring it out is poor outcomes. And collectively as an institution, we’re not going to let that happen. So those kind of situations, although in a markedly different environment, those lessons are serving well.
You talked in one of your messages to the community about — you gave the example of toilet paper, about how if people panic, they’re going out buying toilet paper, but there’s no specific reason related to this virus that that would be necessary. It was kind of acknowledging that people do want to exert some feeling of control over the situation. As it is right now, if people shouldn’t panic, what should they do that might kind of give them a feeling that there’s some proactive steps that they’re taking here?
White: For the average citizen in the community, even if you’re lower risk, you know, pay attention to the information coming from reputable sources, the social distancing kind of thing. You know, maybe it’s not a good idea to hold the event that you were planning, the neighborhood party or the gathering of your friends. Maybe it’s not a good idea right now to engage with so many other people. Because actually not performing those actions — it is a positive contribution to the community.
Considering, you know, what are truly your needs. There are reasonable things for people to be buying up in reasonable amounts. We’ve had elderly patients that are looking at their prescriptions. And if you have high blood pressure, it is a reasonable thing to ask for a few more weeks of that. Because if you can get a few more weeks of that, you may not have to go out into the community, and you’re going to do a better job of protecting yourself from contracting this illness. But that’s a far cry from buying 48 rolls of toilet paper.
Sure. In terms of limiting the spread here — I think you acknowledge this in one of your messages, that this is the time of year when respiratory illness is pretty common anyway. Everybody has their cough or their sneeze or their fever here and there. I think there’s still some confusion among Vermonters about what rises to the level of suspicion that something might be more serious. And then if that’s the case, what to do about it. Who should be their first call?
White: That falls into a couple of different categories. Anything that you would have considered potentially an emergency or cause for concern two months ago, that’s still the same. You know, if you fall and hit your head and you’re on blood thinners, or you passed out, you should probably be seen. And so none of that has changed.
As far as respiratory illnesses and such go, it’s well known that a large percentage of people that develop coronavirus, nothing is really going to happen to them. It may be annoying, you may have a cough, it might keep you up at night, you’re maybe going to have the sniffles. But that’s going to be about it. If you fall into that category, and you’re young and you’re healthy, understand that there’s not a medication for you. We are not going to admit you, and you do have the potential to clog up the system. So your best option is probably to stay home.
Now, if you’ve got other conditions — maybe you’re a severe asthmatic, or maybe you’re older, maybe you’ve got emphysema, and you get a fever and a cough — we know you’re higher risk. And we do want to see you and keep an eye on you. Because that’s the group of people that we worry about. Those people can have a little bit higher threshold to at least call in and ask. And then if something occurs where you’re severely short of breath, or you’re developing chest pain or something along those lines, then definitely come in, don’t stay home. The resources that we’re marshaling, and the increase in our capacity that we’re working on, is for those people.
Given the people who are relatively low risk — who, the recommendation is really just to stay at home — I think there’s still a concern among a lot of people that aside from complete self quarantine, that if those people just need to go to the grocery store, or do the things that people do routinely in their daily lives, that they could be, unknowingly in a lot of cases, encouraging the spread of the virus. Is that something that you think is maybe an overhyped concern in this case?
White: It’s a real thing. But it’s also unavoidable. We’re not in a position where we can all go be hermits. And that right there is why this sort of — just a couple of hours ago, the WHO declared this a pandemic. And the reality that this virus can exist in a person and not make them sick, but still be shed a lot, makes it nearly impossible to control. And so there are lots and lots of people in the world right now that are walking around with coronavirus that feel just fine and are infecting other people.
So what are we left with? Well, we have to be as reasonable as we can. We can’t all move into caves. But you know, if you need to go to the grocery store, don’t take your whole family. Maybe you go on slightly off hours, where you’re less likely to interact with other people. And you do things like you cancel nonessential sorts of activities.
The reality is all our lives are going to change for a while. And this is going to be weeks, if not months. The last commentary I saw coming out of the CDC was talking about eight weeks. And that’s probably eight weeks from when you see the first case in your region. Here in central Vermont we haven’t even started yet. And it may go on even longer than that. So your vacation may be interrupted. Your concert may be interrupted. But collectively that’s the reality that we live in.
To give people even a more specific idea of what’s coming down the road: It seems like this week there was this sort of theme of social distancing; we heard all these announcements about things that were going to be closed or cancelled. What kind of themes or patterns do you expect we might see next week, or the week after that, the very near future?
White: One of the things is going to happen in the near future that’s really important for people to understand is that manufacturers are going to catch up with the demand for testing. Because this was a brand new virus, for obvious reasons, we were unprepared to test for it. And rightly or wrongly, we’re not there yet.
As of yesterday [Tuesday] — I haven’t checked the website recently — the Vermont Department of Health had only performed 41 tests for coronavirus. And that’s because they have a limited supply. And they have to be judicious about whom they test. So they’re testing high risk people and people that are quite ill.
It’s a near certainty that there are a lot of Vermonters running around who feel fine who have not been tested, but do in fact have coronavirus. When the demand catches up for testing and manufacturers release enough tests, you’re going to see a big spike in the number of cases in Vermont. We’re going to go from one case to perhaps several hundred cases in a period of a couple of weeks.
Wow.
White: It’s really, really important to understand that nothing changed. These people were already out there. We have simply defined them. They were there. And there is utility in knowing roughly how many people are out there and where they are. Because in hospitals like this, if I know it’s in the community, that gives me a timeline for when I’m likely to see the surge of sicker patients. So it’s important to do that. At the same time, it’s important for people to understand that this is a steady progression, but nothing changed in the moment you see that sudden spike in cases
What should people be thinking or doing? At that point, should they be changing anything, or they should continue doing what they’ve been doing up to that point?
Continue doing what you’re doing. Understand that we’re just able to test for it. When that happens, when physicians can start to test much more freely, that is not a point that anybody should panic. It was the same as yesterday. Now you can just see the numbers.
After that, it’s going to get into a given community and it’s going to spread. There’s going to be a lot of people in that community that are carrying that virus. And some percentage of a given community is going to be ill.
By community, do you mean like a geographic area or a population, demographic?
White: In this case, the most pertinent definition would be an area that a given health entity is responsible for. So when I think communities, I think, all right, how many patients Is Gifford Medical Center going to be responsible for? Those are the numbers that I’m thinking about when I’m thinking about capacity, and how is our hospital going to sustain that.
Individuals in this community are going to carry coronavirus, and based on the epidemiologists’ data, a lot of us are going to carry it. And then because it is a brand new infection, and no one has any immunity, it’s going to happen all at once. We’re going to have a lot of sick people all at once. We already know who most of those people are going to be and they’re older, and they’re already ill. We’re preparing for that.
At the same time, there is going to be a lot of challenges for a lot of people. If you’re a small business owner, and suddenly your employees have to figure out what to do with their children because school has been canceled, that’s going to be a problem. Even if no one is clearly sick. So you’re going to see a lot of side effects along those lines. Thinking about workforce considerations is going to be important.
This will persist after it’s widespread in a given community for a couple of months, and then there will be a significant percentage of the population with some level of immunity, and it will start to die down. This illness is infectious enough that it is probably going to become endemic. I anticipate — well, it’s hard to say what’s going to happen in the future. It’s going to depend on how fast it mutates. It could become like another influenza, where we see it cyclically. But because people have had it before, there’s some level of immunity, and it sort of fades into the background as another viral respiratory illness.
Do you think we’ll see deaths in Vermont?
White: Certainly. Yeah, we have plenty of older people. The numbers are clear. But, again, context is important. We see deaths in Vermont from influenza every single year. We have deaths in this hospital. And some of those situations are much scarier because influenza also kills young people. You know, this one is a bit more palatable. It would appear that the mortality rate is higher for coronavirus, although that’s hard to tell. But it’s not killing kids, so we can be thankful for that.
Any other big picture things that people should be keeping in mind as they hear this information and think about it going forward?
I would not think of this situation as unique. It feels new and different. But our current global reality is that we have kind of become a global community. People move around frequently and quickly. And we have had tinges of this throughout the past several decades: SARS, the anthrax scare, H1N1, MERS. Diseases move around a lot faster than they used to. And it’s a product of how we all live.
This is not going to be the last time this kind of thing happens. The hope will be that this is going to educate the globe, and we’re going to build much stronger public health systems to manage it. But we will hear about this kind of thing on a periodic basis. And I fully expect, within our lifetimes, we’ll get another virus from somewhere, or another bacteria for somewhere, because that is how we live. And I think that will help people consider, their lives, the impact on the globe, how we all behave, and what that means.
Thanks, Dr. White for your time. I really appreciate it.
White: You’re welcome.
