Strengthening Global Health Systems: An Interview With Vanessa Kerry

EVN Report: At Seed Global Health you work on educating and training healthcare workers in the developing world. Based on that experience, what is the readiness level of healthcare workers in those countries and contexts, when it comes to facing an outbreak like this? 

Vanessa Kerry: As the baseline we have to realize there’s a critical shortage of doctors, nurses, midwives, health professionals and healthcare workers writ large…it is actually expected to grow to 18 million by 2030 if we don’t do anything about it or really scale up our interventions. We are already looking at a gap. That is the baseline — pre-COVID-19.

Countries that have the lowest or the highest shortages of healthcare workers are also the countries with the most crushing burden of disease. And it makes sense, right? Less resources for healthcare workers, less resources to also mount a preventative primary care system, prevention or to address disease burden….you have these crushing burdens of disease that are both infectious and preventable diseases like AIDS, TB, malaria, diarrhea, pneumonia that are the leading causes of death. But you also now have a growing burden of non-communicable disease in terms of cardiovascular disease, which is the leading killer worldwide. You have growing levels of malignancy in cancer, which is the third leading cause of death worldwide. And you have growing chronic obstructive pulmonary disease and chronic pulmonary diseases from smoking, indoor smoke and air pollution that are also now leading causes of death – the fifth leading cause of death worldwide. So you’ve got these crushing burdens of death at baseline and now you’re going to layer on a pandemic. So [coronavirus] is a third, sort of a layer of disease burden in an already stressed system and it’s a recipe for disaster.

Here’s where it gets sort of multi-layered and nuanced: the preparedness of a country also depends on their exposure to something like this before. So West Africa, that had an Ebola outbreak in 2014-2015, actually did a huge amount of building systems for disease identification, triage systems for high risk patients being put into isolation and for training healthcare workers to kind of mount an emergency response and to do contact tracing. [Having] that kind of mechanism and system in place, that could get kind of triggered in a situation like this, put some of these countries actually at a relative advantage to countries that maybe haven’t had to deal with hemorrhagic fever or a very contagious outbreak. Sierra Leone was quarantining people from China, when at that time in January, the disease was highest. They were quarantining people automatically. If you came in from China, for two weeks, you stayed in a hotel right outside the airport before you were allowed to actually enter the country. And as a result, they have delayed their cases immensely because they were very aggressive about border surveillance, quarantine and very proactive about putting in place those measures that could help mitigate any degree of the pandemic.

Relative to that, in the United States, we actually were having people come into a very porous border at that point out of China or out of other places or even from Europe or elsewhere. We were having silent infections spreading around at that point in Seattle. And then, ultimately, it ended up being in New York and you got these massive outbursts.

What we know about COVID-19 is that probably five to six people get infected for every one person that’s infected. And then unfortunately you are infectious in the two to three days before you show symptoms. So Sierra Leone’s aggressive preventative measures probably has helped them stay down to about only 65 cases right now. And that’s four months into a global pandemic when they had huge amounts of movement and people still at their border.

When you look at Uganda, for example, they detected their first case because they were doing aggressive border surveillance. They had a Ugandan citizen who had flown in from the United Arab Emirates on an Emirates flight. Everybody was getting their temperature screened at the border. He had a temperature and they rapidly tested him within three hours. They had the answer that he was COVID-19 positive and they quarantined the entire airplane. So they’re at about 77 cases right now…which is quite extraordinary. And they also have great experience with hemorrhagic fever, have done a lot to increase their preparedness.

My hope is that less resourced countries take advantage of the fact that most of them have not yet been hard hit and take advantage of the fact that they could put in some very aggressive preventative measures that may help mitigate the degree of their infection and that’ll help their health systems that are relatively under resourced be able to address those infections they do see. And that they’ve had the advantage of time to look at lessons learned and best practices across China, South Korea, Taiwan, Hong Kong, New Zealand, Iceland, look at Sweden, Italy, Spain. You know, the good, the bad.

The United States certainly is a lesson for what not to do. There are some important things that we’ve learned. One is aggressive border surveillance. Two is everybody should be in a universal mask policy. And certainly you should save that medical grade mask for your healthcare workers who are on the front lines. But there is no reason we should not all be wearing bandanas, cloth masks…universal mask policy has gone a long way to reduce transmission.

EVN Report: I know how hard doctors and nurses and essential workers in Boston are working. I know how hard everyone at Mass General is working. So I ask this question with a somewhat heavy heart. We tend to think of developed countries like the U.S. being much better off than developing countries in a situation like this. But is that no longer a given? We’re watching the situation in the U.S. escalate with this degree of surprise and disarray. Is it no longer given that a developed country is going to be in better shape than a developing country here?

VK:  So, again, this is a nuanced answer. At baseline, the access to resources in a developed country is better and the ability to have access to a health system that is probably more developed – is better. Which means that, if you put every country in the correct proper preventative measures – border surveillance, masks, hand-washing, contact tracing, if you created two equal scenarios where everybody had access to the same thing, a developed country should be in a better situation than a less resource country, because their health system is better designed.

So to give an example. I work at Mass General Hospital. Clinically, we have been very prepared. We’ve had the ability to surge our ITUs, from two medical ICUs to about ten or eleven medical ICUs. We’ve gone from having on average maybe 20 intubated patients to 180. We’ve been able to do that because we’ve got access to ventilators, staff systems. But we also lived in a state that very proactively put in social distancing measures, physical social distancing measures, advocated for masks in place. [Massachusetts] put in some of these preventive measures to help mitigate the degree of the peak that allowed us to sort of stretch our capacity, but not to exceed it. When we don’t take those efforts, though, and we are delayed in putting any of these things in place, you get into very dire situations like we have seen in Seattle or in New York, for example, where resources have been absolutely stretched to the limits because some of this couldn’t be put in place in time or were put in too late simply because we didn’t know, understand, and there hadn’t been quite the kind of federal leadership. And I think it created confusion about how to respond. One doctor is taking care of 80 intubated patients. That is, there’s no way you’re going to have a good outcome in that kind of scenario.

So I think what we have seen is that leadership matters, policy matters. rankly, that’s been the divide about who makes it or who breaks it in this COVID-19 epidemic. Resources matter, certainly, in what your capacity is and how far you can stretch within it. But it has to be coupled to good policy and it has to be coupled to strong, courageous leadership willing to make the right decisions and put the right information out there.

So in this world we live in now it’s anyone’s guess how a country does. The U.S. has shown that a failure of strong federal leadership to give the right information and to make the courageous and difficult decisions that would have protected us has shown our vulnerabilities. We also have vulnerabilities, though, because we have not systematically, in the United States, for example, put in a universal healthcare or universal primary care system that’s allowed access to services in the right way. So what we’ve seen is that those [Americans] with the least resources, those who have lived in poverty, have not had access to good healthcare, have more comorbidities, more diabetes, more heart disease that has put them at a far worse situation when they get infected with COVID-19. What you’ve seen in states like Louisiana, which is 30% people of color or black, 70% of the COVID-19 deaths have been among blacks. Similar statistics out of Missouri, Michigan, other states, the Navajo Nation…Native American Indian population here is the third hardest hit community in the United States. Now it reflects years of under-investment in the health system there. Extremely high comorbidities, high poverty and really a failure to invest. And so what we’re seeing as well is that policy failures can make a very developed country have issues. But also we have inequities within our own system that are being stripped evident in this moment, which means that we have micro communities that are not better off necessarily than some of these other communities around the world.

EVN Report: You’ve had to make some really hard decisions at Mass General Hospital, including bringing families in to say goodbye when a COVID-19 patient seems close to death. How do you make that call? Do you have any advice for hospitals in developing countries as they try to balance those sorts of ethics and personal elements with the necessities of care?

VK: I think this is a very tricky question. I was not involved in making the policy, though I am grateful for it as a clinician who takes care of patients and by proxy, takes care of families, especially as an ICU physician.

In a pandemic we have to think about the most protective measures…a safe way to bring family in [to say goodbye], that does not expose that family member. That family member is going to go back into the community, back to care for other members of the family [at home]. I think if there is not a safe way to do that, you need to think about putting a different system in place, whereby maybe the family member has to say goodbye in the moment that they drop somebody off or they separate. I know some hospitals have instituted that system because it’s the safest thing to do and you have to do it.

I think that what is important is to recognize what the risk is up front and to think about the procedures and protocols, so that there is some ability to kind of create space for that moment of uncertainty and mourning and a chance to say goodbye. I know the one thing that has always been hardest for families is when they say, I never got a chance to say something I needed to say [to a loved one who passed away].

The important thing is to consider what you’re capable of doing in your facility and creating a policy that is safest for everybody. And to think about what triage and infection prevention looks like is probably one of the most important things for facilities to think about — how do we screen, what is our clinical diagnosis of COVID-19, especially in the absence of testing, what are we going to decide and how strongly do we want to rule in for COVID-19 on a clinical basis, meaning not testing, but saying you fit this criteria, how [lax] do we want that to be? And then where are we going to put those patients? Are we going to put true COVID-19 positive, confirmed patients all in a single isolation ward? And what’s helpful about that is that you may have a no visitor policy on that ward because the risk is too high. You also have the advantage potentially, as a provider, to wear the same PPE between patients. You don’t have to worry about taking it off, putting on, putting yourself at risk. You walk into that COVID-19 ward, you put on your gear, you stay in your gear between patients, because all patients have COVID-19. It’s that kind of preparedness, infection control and thinking about ways to streamline workflows that reduce risks to your healthcare workers. And part of that is going to be thinking about how family interacts.

There are ways that people have used plexiglass booths or plexiglass shields, at least to mitigate the transmission across folks or to facilitate conversations. But it takes forethought. And I’m always encouraging taking the time now to build those best practices, to reach out to colleagues in other countries that are dealing with COVID-19 to understand what their best practices are. The WHO is putting some information up, which can be very helpful. The Society of Critical Care Medicine has been putting up some very good stuff, excellent webinars, teachings, training, refreshers. But preparedness is the key to dealing with COVID-19.

EVN Report: What innovative solutions have you seen for the preparedness and protection of healthcare workers around the world in these resource constrained environments? 

VK: I think this is a very active debate because the cases, at least in sub-Saharan Africa, in the countries where we work [through Seed Global Health] have remained fairly low. So we’re not in South Africa, for example, that just had up to 3000 cases. And I think that what has been happening really has been an effort to make sure that there is a clinical protocolized diagnosis…that those who are doing the screening are sitting there in proper equipment, you have an isolated, designated person doing the screening at a safe distance away — six feet away — to do the interviews [with incoming patients], deciding where patients get triaged and then flagging who might have COVID-19. As healthcare workers, you can then ensure that as they move through the chain, the next healthcare worker is protected.

I think that being judicious about, unfortunately, reusing PPE is critically important.

We’ve been using a single mask at Mass General a day and it’s very uncomfortable. I just realized no matter how hard I tried, I was contaminating it myself. If I ate anything during the day, I was very careful to take off my mask in an isolated area to sort of unpack food, to not touch it in any way, shape or form. If it came in a wrapper, I would just hold the wrapper, eat the protein bar. In my case, I’d have one protein bar a day, during my entire shift and then would put the mask back on and assume everything was contaminated. Then I would go home and take my clothes off before I walked in the door. I would leave my shoes in a designated spot as far away from anywhere in the house my children or my husband or anybody would walk. Because we know that COVID-19 stays on the bottom of shoes. I would actually leave my clothes outside as well in a designated spot to be put on the next morning. I would come in the house, use a separate bathroom and would just wash everything that I just presumed was contaminated. That’s the best I could do and then would get dressed and rejoin my family.

I know some of my colleagues have stayed in masks at home. That was a discussion my husband and I had that we thought would be too distressing for the children. So I would just take every precaution while in the hospital and then try to mitigate kind of my close interaction. The truth is, that’s impossible. So we’ve just been a little bit fingers-crossed and hopeful that the mask and everything have worked out. But I think it’s about just being thoughtful again, also about workflows at the hospital, about trying to create a COVID-19 zone where you go in, you’re not taking the mask on and off as much as possible. You are trying to find a system of reusing masks in the safe way. Face shields or goggles are very important. And we’ve also instituted practices where we’ve tried to minimize essential personnel, so that as few people as possible interact with COVID-19 positive patients. We are still having residents, fellows and trainees join because they are clinicians, they need to learn. But when it’s an actual procedure where we think [the virus] might be aerosolizing, we definitely [limit access to] those procedures in this acute moment to only those who absolutely need to be there.

EVN Report: You’ve mentioned that in the developing world, even if you get all the ventilators you need for COVID-19 patients, you need to scale up the training for healthcare professionals that can use them. How do we scale up that training – fast – to meet the needs of this moment?

VK: It’s an excellent question. At Seed Global Health we are huge believers of the importance of people powered education. For any kind of healthcare delivery you need mentorship, you need somebody to show you how to do it. It cannot just be done through telemedicine.

The ways to do it are to prioritize those available educators or physicians, nurses, midwives who are in-country, but might be working in the private sector. I think we need to buy them out, in part, to come in and provide education and training and to put those skills to work in the public sector and to use them and support them to help provide some of that in-person education and training.

You can augment through telemedicine. It goes a long way if you could at least visualize, see webinars and things like that can be very helpful. But there needs to be a system of ongoing education and ongoing mentorship so that as we encounter these cases, [getting real-time support] or having a clinical case discussion with somebody who’s already dealt with this in New York or Boston or Egypt or somewhere else. We are trying to build a kind of a global on-call system where we can create a linkage in real time to support people through the management and care of these patients. There are ways to do it. We’re trying to do it at Seed. We need more resources because it’s kind of a new model that we’re trying to scale.

Through a combination of telemedicine, drawing on existing staff that maybe aren’t in the public sector support and using some of the online resources that are available, like through the Society of Critical Care Medicine or others…it can go a long way. Mass General is also mounting a whole platform for this kind of education and training to make these resources available.

One of the most important things is going to be how do you accompany someone through care? Because when you’re on the front lines in a twelve hour day and you also have a family to take care of you don’t have an extra hour to sit through a lecture. But maybe you just need a quick phone call to run through a case for somebody. And I think that kind of platform is going to be one of the most important ones we could create to support folks. I would encourage facilities in resource limited settings to think about finding a partner facility or somebody who could help provide that kind of accompaniment and support to their frontline staff that are addressing these cases, because it’s a little bit more facile to the daily workflow. If you can just look up and say, oh, there’s this person kind of on call. We’re trying to do this at Seed Global Health because we think it’ll have one of the highest yields in terms of support.

EVN Report: How do we build a global health system to support all countries, even resource limited ones, especially if we think these epidemics are going to be coming at us again in the future?

VK: It’s critically important to recognize the value of an entity like the WHO. The U.S. decision to cut funding right now is absolutely disastrous because the WHO has the ability to be a nonpartisan entity that can gather information from across countries, create a scaled system towards research, towards information delivery. They created a solidarity trial, which is something like 47 countries, looking at interventions and treatment of COVID-19, which allows us to look at those interventions across multiple settings, multiple populations, multiple phenotypes, genotypes, all of these pieces. That’s very powerful. When you’re in a geopolitical war with another country, you may not be willing to share that kind of information.

So entities like the WHO are critically important. Funding them is critically important because the more bandwidth they have, the more ability they have to generate and adapt protocols for resource limited settings. This is what COVID-19 care looks like when you have only one ventilator in your country, or five ventilators. The vast majority of your patients are not going to access a ventilator. How do we care for a patient? There are interventions we can do when we know that 5 percent of cases are going to meet critical care needs. Some of those [cases] we can still mitigate with oxygen. Oxygen alone is so important. We’re not talking about [the use of] oxygen enough, yet it’s a very powerful tool in the treatment of COVID-19.

So adapting those protocols is really important. The WHO is empowered to do that, they can do that at scale and disseminate it readily. Building a global health system is one, a universal recognition that health security is national security, is global security, is economic security, is individual and community security, period. Which means we all have to invest in our health systems. We have to invest in surveillance. We have to invest in research. We have to share information. We have a natural support network, the WHO, to help us do that. But then we need to empower it better.

EVN Report: Have you been dismayed at this sort of “law of the jungle” or law of the markets that’s out there, with countries outbidding one another for PPE? Plus concerns about access to drugs or, eventually, equitable access to vaccines? What does it mean for the developing world if there is this sort of dog-eat-dog approach to global health procurement?

VK: I think the fact that more resource endowed countries are in a position to kind of create markets or to outbid one another for resources is definitely going to hurt the less resourced countries of the world, because they just don’t have the market power.

We saw that [shift] with HIV, actually. When there was a universal market created for HIV drugs, it dropped the price of drugs for patients. That was very powerful, creating that universal market. And that’s probably what’s going to have to happen here. It’s that universal purchasing power that gets created when you bring [many countries] together.

If we created a global system of mapping where the epidemic is worst and moving the PPE to those places in waves, it would be very effective. China now has an excess of PPE. We should be moving that towards where the hotspots are. Everybody can win if we work together. When we start getting into a divide and conquer, or kind of hoarding mentality, we’re going to have a hoarding of resources in some places that don’t need it while people [elsewhere] are dying because they can’t access it. And it just doesn’t make sense.

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