Lessons from COVID-19

On October 28, 2020, as infection rates of COVID-19 were surging for a second time, Yale School of Medicine and Yale New Haven Health conducted a virtual town hall aimed at convincing clinicians, faculty, staff, and trainees to seek help if they were feeling anxiety, depression, or other symptoms related to demands on them in the midst of the pandemic.

Five clinicians and administrators told of their own struggles with mental illness and occupational burnout. One of them, Michael Ivy, MD, the deputy chief medical officer of YNHH, had battled depression earlier in his career. After the town hall, he described why he was willing to speak out to colleagues. “In health care, there is a belief that if you ask for help with mental health struggles, your career is over,” he said. “I wanted to let people know that not only is it okay to ask for help if you need it, but you can thrive because you asked for help.”

The virtual town hall was one of multiple programs developed during the crisis to help workers cope with the severe stresses they faced—the long hours, the seriously ill and dying patients, and the risks to their own health and that of their family members.

This outcome was one of the significant takeaways from the COVID-19 disaster. No longer could the medical profession and health care system fail to ignore the toll of stress and mental illness on their own people. “We need to promote self-care as part of the professional lives of faculty, staff, and trainees,” said John Krystal, MD ’84, the Robert L. McNeil, Jr. Professor of Translational Research, professor of psychiatry and of neuroscience, and chair of the Department of Psychiatry at Yale School of Medicine and Yale New Haven Hospital (YNHH). “We need to address the stoic culture of medicine. People are reluctant to identify themselves as needing help and hesitant to get help. We have to change that.”

Lessons from the outbreak of COVID-19 disease are profound and far-reaching for hospitals, clinicians, researchers, and medical schools. In department after department at Yale School of Medicine (YSM) and YNHH, which operate in parallel, leaders say the crisis marked a turning point in how they think about their jobs and how they get things done—and it should be a catalyst for more broadly transforming medicine.

Gary Desir, MD ’80, the Paul B. Beeson Professor of Medicine and chair of the Department of Internal Medicine at the school and hospital, said changes must take place at multiple levels. First, the public health system in the United States needs to be bolstered; it has been underfunded for years. Second, the medical profession has to widen its focus by not only studying and treating individual diseases but also seeking to improve population health outcomes. And last, the medical establishment must recognize and help correct health inequities. “Black and brown communities have suffered more in both the number of COVID infections and complications,” he said. “If we needed confirmation that there’s a problem, this is it.”

In addition, leaders of health care and medical science recognized the need to address global issues that the crisis has brought into clearer focus. Because of population growth, environmental degradation, and climate change, it is likely that there will be larger and more frequent public health disasters in the coming years and decades. Disturbance of wildlife habitats leads to the spread of infectious diseases from animals to people. In a recently published report, the British journal The Lancet draws direct connections between the COVID-19 crisis and climate change. “The window of opportunity is narrow, and, if the response to COVID-19 is not fully and directly aligned with national climate change strategies, the world will be unable to meet its commitments under the Paris Agreement, damaging health and health systems today and in the future.”

New Haven’s awakening to the COVID-19 crisis was a bit like the beginning of World War II had been for the mainland United States. The pandemic started in a far-off place, spread gradually at first, and suddenly it was in our backyard. On January 23, 2020, just two days after a World Health Organization (WHO) team arrived in Wuhan, China, to investigate the disease outbreak, Saad Omer, MBBS, MPH, PhD, director of the Yale Institute for Global Health, warned in a New York Times op-ed that the novel coronavirus could become a global pandemic if it were not handled correctly. He urged political and health care leaders to heed the lessons of earlier outbreaks, including severe acute respiratory syndrome (SARS) and Ebola. “Be ready for anything, and leave it to the experts,” he wrote.

The disease did spread worldwide in subsequent weeks. The outbreak in northern Italy in early March 2020 got the attention of health care leaders at Yale; they began to plan for the worst. On March 11, the WHO declared the outbreak a pandemic. The first patient with COVID-19 was admitted to Yale New Haven Hospital on March 13. Within a few days, the emergency departments (EDs) on the two New Haven hospital campuses were flooded with COVID-19 patients. Then the intensive care units (ICUs) were full, and many of the regular beds were converted to handle COVID-19 patients. At the peak of the crisis in April, there were 447 COVID-19 patients on the New Haven campuses. “There will always be crises and disasters. We train and prepare for that,” said Gail D’Onofrio, MD, MS, the Albert E. Kent Professor of Emergency Medicine and chair of Emergency Medicine at the school and hospital. “But this was different. It wasn’t over quickly. It just kept going, and it wore our staff out.”

The emergency departments adapted to the flood of patients. They quickly changed their protocols to deal with social distancing; using personal protective equipment (PPE); and frequent cleaning of surfaces and computer keyboards. Within days, clinicians set up a tent outside the emergency department on York Street so that they could do evaluations immediately when sufferers suspected of having COVID-19 arrived. Clinicians in the ED developed and validated a 12-point COVID-19 severity index for guiding the treatment of sick individuals. This index helped the hospital manage a surge of patients that on occasion left 50 to 80 people waiting in hallways for admission. In early December, there were more than 180 COVID-19 patients on the New Haven campuses and the ICUs were nearing capacity. YNHH had learned from the first surge, however, and had stockpiled PPE and ventilators in advance of the second one while optimizing its treatment protocols and testing procedures. The EDs were ready for whatever might come.

In spite of the heavy patient workload, ED clinicians wrote more than a dozen articles for scholarly journals about dealing with COVID-19 and pandemics. One of the key lessons they learned was to avoid putting COVID-19 patients on ventilators too soon. The patients might not need them; and once somebody was on a ventilator, it could be difficult to wean them from it.

Because of the influx of COVID-19 patients in March and April 2020, the New Haven Hospital campuses suspended many of their more routine services. Surgeons, anesthesiologists, and other internists as well as specialists with the appropriate experience were pressed into service in the ICUs and on medical floors; they helped wherever they were needed. In the early days, daily coordination meetings were held at the university, medical school, and hospital floors—often involving people from all three. In Internal Medicine, Desir created a COVID response team that met every morning for three months. “The big lesson from the first wave was [that] we all had to come together as a team, and we had to make decisions and do things much more quickly,” he said. A key example was the fast and massive shift to using telemedicine in place of many in-person clinical appointments.

The greatest early challenge for clinicians was that so little was known about the disease—from how it spreads between people to how it affects the body. Initially, no medicines were known to be effective against it. Over time, through experimentation and rapid studies, clinicians learned that the drug remdesivir and certain steroids helped address symptoms in some cases, but that hydroxychloroquine was not effective—even though it was touted by politicians and some physicians. “There’s a lesson here that we know but often forget,” said Desir. “When a new disease comes along, never make declarative statements about it because you just don’t know much. You can quickly lose the trust of your colleagues and of the public.”

In those early days and again in December 2020, staff members of all types in the hospitals and clinics were nearly overwhelmed. They typically worked extra hours or extra shifts—increasing the strain they faced in balancing the needs of their work and their families. The result was stress and fatigue; and in many cases, symptoms that included anxiety and depression. “One of the biggest challenges was that many people were so exhausted and emotionally depleted that they didn’t have one extra ounce of energy to deal with their own self-care,” said Krystal.

To deal with that conundrum, leaders at the hospital and medical school developed a number of new programs by redeploying staff resources and recruiting volunteers. These initiatives were designed to make it easier for clinicians and staff members to get help—a “mental health safety net,” according to Samuel A. Ball, PhD, professor of psychiatry and associate dean for faculty affairs at the medical school. Early on, the leaders sent out an anonymous self-assessment survey to monitor health-system-wide stress levels and direct people to the appropriate resources. By early December, the survey had been used more than 18,000 times. The new programs included a series of virtual town halls; hospital-based wellness check-ins; a discipline-oriented buddy system; and a counseling program. The idea was that different people would respond to different offerings based on their needs and willingness to engage. There are several key findings from the programs so far, according to Krystal: first, no single intervention works for everyone; second, it’s important to adapt quickly to changing needs; and third, leaders need education and outreach to raise awareness of mental health issues and to convey how easy it is to get help.

One of the initiatives connected employees who asked for help to psychiatrists, psychologists, and social workers who were willing to pitch in on a voluntary basis. This confidential one-on-one consultation program was developed jointly by the Psychiatry Department and the Yale Child Study Center. It was led by Ball and Claudia Moreno, MD, assistant professor of clinical child psychiatry and medical director of consultation-liaison services at YNHH Children’s Hospital. More than 150 clinicians volunteered to provide one to four acute stress intervention sessions free of charge. They referred employees who needed ongoing mental health treatment for further care. By mid-December, 70 employees had taken advantage of the program. Moreno said she hoped COVID-19 awakens the medical establishment to mental health issues among health care workers—including making some of the new programs permanent. “We have to take away the stigma and provide opportunities for relief and recouping,” she said.

While the departments of Emergency Medicine, Internal Medicine, and Psychiatry were on the front lines of COVID-19, people in nearly every department and function at the medical school and health system pivoted from what they were doing to focus on the crisis. It was an all-hands-on-deck situation.

In Pathology and Laboratory Medicine, practically everybody was pressed into service on testing and diagnosis programs. While the team members used a variety of tests, a consensus quickly grew that the molecular (PCR) tests were superior because they were the most accurate even though it took longer to get results—as many as five days early on. “My regret is we were not totally automated,” said Chen Liu, MD, PhD, chair and Anthony N. Brady Professor of Pathology. He’s now investing in new diagnostic equipment and techniques. CRISPR gene-editing technology is being developed for COVID-19 testing, for instance. Moreover, the new technology platforms have potential for clinical diagnoses beyond COVID-19.

In the clinical trials programs, Onyema Ogbuagu, MBBCh, associate professor of medicine, switched from a focus on HIV/AIDS to COVID-19. He became a principal investigator on multiple trials, including those of remdesivir and the Pfizer/BioNTech vaccine. The Pfizer and Moderna vaccines were developed using a new approach to vaccine development—the mRNA platform. Rather than implanting weakened or inactivated virus cells in our bodies, these vaccines use single-stranded molecules of RNA to trigger immune responses. The platform is not only faster than traditional vaccine development techniques, but also less risky for patients. Virologists hope the mRNA techniques will be useful for other viruses, including HIV.

The biggest lesson from COVID-19 in the drug development sphere was the importance of information sharing and collaboration, said Ogbuagu. Two days after China shared the genetic sequence of the virus, scientists around the world produced corresponding mRNA. BioNTech invented the vaccine but needed Pfizer’s corporate muscle to help develop and distribute it. Pfizer needed clinical trial programs like Yale’s, which are especially adept at recruiting people from the heavily affected Black and Latino populations. The U.S. Food and Drug Administration (FDA) helped accelerate development, including combining phases II and III of clinical trials. “This galvanized the community like never before,” Ogbuagu said. “You wish things worked like this always.”

Even while COVID-19 was raging, medical scientists were busy trying to figure out how it works and what could be learned that would benefit medical science more broadly. Researchers from Yale School of Medicine and Yale School of Public Health combined forces to create a shared repository for new information about the virus and the disease. They enrolled more than 300 COVID-19 patients at Yale New Haven Hospital to provide information including tissue samples for a wide variety of studies.

One of the organizers of the initiative, Shelli Farhadian, MD, PhD, an assistant professor of medicine specializing in infectious diseases, used some of the data for her research into the coronavirus’s effects on the brain. Soon after the first surge began, it became clear that many patients exhibit neurological symptoms, including severe headaches, seizures, and confusion. Farhadian and her colleagues established that the virus was indeed causing abnormal immune reactions in patients’ brains. They hope these investigations may lead to new approaches to treatment that might modify the immune response in the central nervous system, including the possible use of immunosuppressants. There’s an important lesson here. “When thinking about symptoms and damage caused during a severe infection, we have to think about two sides: the damage caused by the pathogen and the damage caused by the body’s overreaction to the pathogen,” said Farhadian.

Some Yale researchers are already turning their attention to the next viral threats. Erol Fikrig, MD, the Waldemar Von Zedtwitz Professor of Medicine (Infectious Diseases) and section chief for Infectious Diseases, regrets that most of the medical community’s response to the coronavirus has been reactive. “Hopefully, for future pandemics, we’ll be proactive,” he said. That will require massive financial investments in identifying and studying emerging microbes. Fikrig believes we must develop tools for fighting viruses that are not pathogen-specific—for example, new techniques for stimulating the body’s immune system that suppress viruses without causing overreactions.

The Yale School of Public Health is also looking toward the future. The school’s dean, Sten Vermund, MD, PhD, the Dean and Anna Lauder Professor of Publich Health, said government and health care leaders alike need to do a better job of heeding the lessons from each epidemic or pandemic and preparing for the next ones. “You need to keep working on medical problems even if they seem to go away,” he said. “I hope that policymakers have been disabused of the notion that prevention is a luxury rather than a necessity.”

For Omer, a key lesson from COVID-19 is that the medical community must speak out loud and clear, not just about the science of diseases but also about the appropriate social and governmental responses. He proposed a forceful communications plan for overcoming resistance to vaccines in an op-ed in the Washington Post, which was published on November 30, 2020. “I believe that universities bring substantial expertise to the table, which has been sorely missed,” he said. “We have to reach policymakers at different levels and the general public. We have to inform opinion on a mass scale.”

The COVID-19 crisis demanded a lot of health care professionals—and they responded admirably. It seemed like a symbolic turning point in the battle when Yale New Haven Health arranged for five employees to receive the Pfizer vaccine in front of television cameras on December 15, 2020. One of the five was Ogbuagu, who ran Yale’s clinical trial for Pfizer. He spoke from the heart. “As a researcher who worked on the vaccine; as an infectious disease specialist who has been on the front lines of caring for patients with COVID-19; as a dad of three kids who are never impressed by anything I do; as a person of color, it has been really gratifying to be part of this process,” he said. “The message today is that this is the beginning of the end of the pandemic. We all need to get this thing, to roll up our sleeves, and move on.”

His message was directed at the general public—imploring people to get the vaccine. But it could just have well been aimed at the health care and medical establishment. The COVID-19 crisis was a wake-up call. Will it lead to long-needed changes?