Interviewer(s): Henry
Interviewee(s): Manassa

Henry: And just to be clear, in the final product, if you quoted, your real name will be used and any organizations that you belong to will only be alluded to.

Manassa: OK, So how would that appear? Like, what would be an example of how that would look?

Henry: It would be, you know, a fake name. Say, uh… Manassa, an M.D. at a large clinic in New York City.

Manassa: Got it.

Perfect.

Henry: OK, so let's get started. How old are you?

Manassa: How old am I? I am [early 40s].

Henry: And where are you located?

Manassa: I am located in the Bronx, New York.

Henry: OK. And what's your position?

Manassa: [infectious disease, antibiotic stewardship, covid credentials]

Henry: So what were your roles in January 2020.

Manassa: In January, 2020, I was still conducting business as usual. I was seeing patients as usual in the hospital, in my clinic. I was overseeing the one of our training programs. I was overseeing the stewardship program. I was doing all the same things I'm doing now. But I was just gathering information about COVID, about what was happening in Wuhan and what they were thinking was the cause of this new deadly respiratory virus, how they thought it was transmitted.

I was just keeping an eye on that. As is my job with any new transmissible and this people ask questions all the time. Sorry is a typical New York City car alarm. You remember. So I was just kind of gathering information in the background and it was not clear at that point what the threat level was to us here in the US.

Our last experience with a global pandemic, I guess for the two prior experiences were Ebola, which really didn't turn out to be anything here in the States. And each H1N1 influenza, which was kind of before my time, but it too was not nearly as, I think, lethal as what they anticipated it was going to be. And then just prior to COVID in 2019, we had a local measles outbreak, which was kind of predictable.

It was among a vaccine under vaccinated or unvaccinated population. They were vulnerable to measles, and it's pretty predictable. There are always pockets of measles activity resurgences in communities where the vaccine uptake is poor. So that was the thing that we had dealt with most immediately before So we were basically business as usual, but just trying to learn as much about it as possible.

Henry: OK. So let's go back. Can you tell me about when you first heard about COVID.

Manassa: Yeah, I was probably like gosh, I think it I can't I can't recall if it was the news or if it was one of these New England Journal of medicine breaking reports or it was, uh… I remember reading something also in an outlet called Stat News. It was one of these publications. It's geared toward other physicians and the medical community that broke something about a virus that was a severe respiratory illness similar to SARS number one, and that it was definitely something to watch.

Henry: Something to watch. Why?

Manassa: Because of the experience of SARS, number one, which again, predates me. But that was a very clearly you could put that in the category of pandemics because it crossed multiple borders. It was highly it was deadly, but transmissible enough to infect numerous individuals. And this seemed to have characteristics of that in terms of just pathogenesis. What kinds of what kind of illness it was causing.

And at that point, we didn't really know, is this going to be a disease in everyone? Is this thing so transmissible and deadly that anyone can become ill or is it preferentially infecting the infirm? We didn't have enough information at that point.

Henry: So when did you start realizing everyone could get it.

Manassa: When more and more reports from Wuhan of younger folks getting in, younger health care providers, some even passing away and within a few weeks, it was confirmed that this was a person to person transmission, not just livestock, to person or environment to person. So that became pretty clear very quickly. It just it unfortunately took public health organizations a little bit longer to be open and upfront about that.

But that was known pretty early.

Henry: Organizations like Chinese organizations or international.

Manassa: Oh, both. Oh, I think well, Chinese public health organizations, I'm guessing, were well-intentioned and really wanted to communicate with their partners abroad about what they were seeing. But they their hands were tied by the government and so by the time they felt… by the time there were more transparent with the information they had, it was unfortunately already too late.

But had that not happened, we may have discovered certain things sooner. That is definite person to person transmission, possibly of airborne transmission exists in addition to two kind of respiratory droplet based transmission. I can't- it's impossible to know how much that those decisions set us back then. I mean, this thing is morphed 100 million times and is very highly transmissible.

So who knows if any early policies would have actually changed the course of what happened. But the question remains.

Henry: So at this time, by the by this point, you've seen human evidence of human to human transmission, droplet borne possible airborne. Can you tell me about how that changed your perception of the crisis?

Manassa: Yeah. Located in New York City, where there's a huge international community, lots and lots of travel. You know, very quickly in the New Year, we were preparing ourselves to to see this. We didn't know in what abundance we would end up seeing and care and taking care of it and really transforming our hospital into a COVID hospital. But we were certainly mentally and infrastructurally preparing ourselves to get a cases of this to the hospital where I mean, that's that's kind of one of the things in a large metropolis that, you know, it's one of the ongoing challenges.

We were one of the first places to really see it badly including the Pacific Northwest. But we are also, you know, fast forward all these different cycles from the different variants. They frequently, especially lately have been ignited in the Northeast and then spreading to other parts of the country. So it's always us first. It feels like.

Henry: New York number one.

Manassa: For better or for worse.

Henry: So you said you didn't know in what abundance. And so you the scale was not clear at first. Can you tell me about when you realized the scale of the problem.

Manassa: The scale problem? Oh, my goodness. Very quickly, within once New York City saw our first case, which like a couple of different institutions sort of shared the patient in the fallout from that patient The doubling time was extremely fast. And at first they thought it was going to be travelers from Asia. Then they thought it was going to be, you know, a certain community in southern Westchester.

And people really. And then, gosh, within no time, everyone every single name, regardless of background, heritage, religion, race, creed, everyone was at risk and vulnerable. And any preconceived notions about who is going to bring this in to to our system or what they're going to look like or any of that, we quickly, very quickly debunked.

Henry: Everyone see prejudices, but did those perceptions hinder the response at all.

Manassa: I don't think so, no. What hindered what was it biggest impediment back then was testing was the ability to really confirm what our diagnostic impression was of anyone presenting with respiratory symptoms. However milder, however, serious. There was a period of time in the very beginning in like mid early mid-March, where you would take sick. You would have to get a special permission to send a test out to the health department and then, you know, would take days and days to get that result back.

And so the number of patients very, very quickly overwhelmed that. But our clinical laboratory colleagues really, really stepped up to the plate and found a way to test. You know, hundreds and thousands of people very quickly turned those things around. Our medical school started developing the equipment to do testing. Medical students were deployed to the lab, deployed to testing deployed to the hospital to take care of patients.

We mobilized very, very quickly, not just us, every every hospital that has needed to do this which is in every hospital in America. They have real success stories about how quickly they're able to mobilize the effort needed to to care for all these patients.

Henry: Can you tell me a little bit more about that mobilization process.

Manassa: Right. So there is a team of people in the hospital. It's called the Department of Infection Prevention. Who deal in these transmissible illnesses. They deal in things that are passed from person to person that spread within the hospital, that can be a real challenge. Sometimes they're refractory to treatments, things like that. And so that that department was sort of like the central to their to the response, meaning how how do we protect patients from getting this?

How do we isolate the patients that have this how do we prevent it from spreading around the hospital? So it's been like the group of individuals in every single hospital and really in the world whose job it is, is to kind of control outbreaks within the hospital testing mobilization. I describe it that was a huge, huge aspect of this.

And then we also had a very good kind of disaster management, a lead who very quickly was able to help us mobilize things we needed, like EMS, transport, you know, refrigerated trucks, ventilatory equipment, that was secured from FEMA and getting it, getting all sorts of help from all sorts of places. And so they're at a certain point, every single person in the hospital, regardless of what their day job was, stopped doing that.

And quickly pivoted to doing something toward the response for Covid. So like laboratory researchers stopped working on whatever heart disease and pivoted to working on COVID Kobi Diagnostics, COVID antibodies whatever, testing all kinds of things. So everybody, every single person top down was mobilized to help in some way.

Henry: Were these teams in place before COVID?

Manassa: No, no, not really. There's some fundamental things in place, like the Department of Infection Prevention, the Department of of Patient and Environmental Safety. Those things are part of the day to day operations of the hospital. But these things had to be quickly padded and built up so that they could deal with all kinds of other disasters that were a consequence of the pandemic.

So we had to definitely create on the spot New programs, new you know, a huge telehealth program to manage all these patients outside the hospital. Every every new phase of the pandemic. We had to kind of adapt to that and build around it.

Henry: It seems pretty successful from an organizational resilience point of view.

Manassa: I would say so. But, you know, studies show that when a hospital is in surge conditions, meaning that the majority of their cases are COVID patients, and they have to open up new wings to take care of COVID patients, and they have to mobilize new staff, staff that may work in pediatrics now has to take care of adult patients, you know, things like that.

Very clearly, studies show that not only do the COVID patients get suboptimal care, but anyone else who's in the hospital during that period of time will get suboptimal care as well. So if you happen to be in the hospital in March of 2020, you're going to our hospital, any hospital, any hospital in America that was surging at the time, if you're in the hospital for elective procedure or something totally unrelated to COVID, there was a high likelihood you could contract COVID in the hospital because we didn't have enough protections in place, or that because the entire staffing model was diverted to provide that your care for your condition was suboptimal and hence, you could

have had a better outcome So that is very clear. Now, we know that bad things happen both to COVID patients and non-covered patients during these surge conditions, which is why now the federal response has been entirely geared toward just keeping patients out of the hospital altogether.

Henry: Was there any fear at the beginning, like February and March, that it would become a nosocomial thing?

Manassa: Oh, yeah. Before it happened, we weren't thinking that much about it. Once it hit our shores and we went from one patient to ten to 50 to 300 to 3000. Oh yeah. We were seeing all kinds of transmission inside, outside the hospital everywhere. And it just it just felt like it was everywhere because we just didn't know enough about it at the time to really shut down these chains.

Of transmission or you know, of course there was a period of time we didn't have enough equipment to do so, but that changed that turnaround pretty quickly.

But the collateral damage of that was many patient, many staff members and patients got sick in the meantime with some bad outcomes.

Henry: Do you think that was because of the lack of equipment?

Manassa: That was a huge factor. A huge, huge factor is probably the number one factor, to be honest, because once we we knew how it was being transmitted, we just couldn't break those chains because we didn't have the right type of equipment or equipment was being used or whatever and that was a big part of how badly people were doing and how many people were getting infected at the time.

Once we once that was … once we plugged that hole, the outcomes were dramatically different.

For at least for people caring for these chains of transmission within the hospital.

Henry: Are you referring to the N95 shortage.

Manassa: it wasn't just N95s. It was it was isolation gowns. It was anything any part of the head to toe equipment that you would wear to take care of a COVID patient. All of that was not immediately available, but mobilization, thankfully, we got I remember at one point we had gowns from South Korea. We had masks from China. We had shields from wherever else.

And we were open to taking all of it. But once that stuff came through, it was like a huge sigh of relief. It didn't matter that like I look like a Ghostbuster and the next guy looked like a normal nurse or a physician. And, you know, we were all we all look not uniform, but it was a huge blessing once that stuff did come through.

Henry: I heard at some places that nurses and other personnel were banned from wearing N95s you heard anything about that?

Manassa: Mmm-mmm. We were never banned. There was, of course, always some debate before things were truly confirmed in terms of the science. Exactly what is the are the primary modes of transmission?

Henry: Never been I didn't hear about it in the context of your hospital system.

Manassa: It was I never heard about it anywhere.

Henry: But maybe it was for a specific it didn't seem like it was coming from like the ID department. It was I think it may have just been individual managers. OK, so did you have it so did you have any kind of like stockpile before this happened?

Manassa: Yeah, there's always there are always you know, hospitals always have to keep these things available for known illnesses like tuberculosis and other transmissible illnesses. You're required to have some general amount available and ready to to order and replenish these stores just to take care of what we already know about. But, you know, unfortunately, we didn't used to keep a lot of those around before as or as many as we do now because a TB patient is rare.

And there's like maybe one on each floor on some floors, but we didn't our needs for those things were not really that robust prior to this.

Henry: And I seem to remember during after Hurricane Maria, there is an IV tube shortage. Did you have to deal with that?

Manassa: Yes. Yes. Thankfully, that was rectified before the pandemic, to my knowledge. So that was like in 2018 or something. And there was it wasn't just tubing, it was IV bags, it was saline, it was a bunch of stuff that did, that certainly did affect us that we had to kind of work around that, especially with intravenous antibiotics and such.

So I do recall that. But thankfully that was mostly alleviated by the time the pandemic came around. But, you know, there were other things that were very difficult because of these supply chain issues that remain that remain an issue. Believe it or not, the I.V. tubing thing is back. Like that's again, once again an issue that forces us in the hospital to be really creative and find these kind of hacks to deliver the same care so yeah.

So there are there are there are certainly things that we had to pivot quickly to do, doing things differently because certain things were not available to us.

Henry: And the original SARS was before your time, right?

Manassa: Yeah, it was before my time. I don't even think I was in med school yet. Yeah.

Henry: Was there any talk about comparisons to the original SARS?

Manassa: Yeah, there were. That happened pretty quickly. I think they recognized that there were certain features or behaviors the way it kind of looked in the microscope. So by the time they did genetically sequenced a virus, they found some similarities. They knew it was a Corona virus very early on. They knew it was in that family of viruses. And so that was the first the very first thing they were connecting it to so that was recognized.

But SARS didn't really hit us at all in the US.

Certainly in Toronto and places. But it, it shared behavior basically with ours. And then it shared a lot of molecular features with SARS I guess.

Henry: Well unfortunately didn't share the behavior that didn't hit the US.

Manassa: Right, right. That is true. And it burned out in a faster timeframe. I mean, we've never seen SARS one again and we're not able to get stars to see to that point where it's that type of virus that is dies with the host, with the last host or doesn't spread as efficiently. Unfortunately, now the virus we're contending with is the most efficient spreader that we've encountered to date.

I think they're now comparing it to measles in terms of how quickly it spreads but it may be also losing steam in terms of causing really very severe illness. It's not so clear if we do that or the virus did that. we meaning our immunity, or is the virus just becoming just kind of losing steam in terms of virulence over time?

Well, we'll have to see.

Henry: But it doesn't seem like it's particularly virulent. It's just the numbers, right?

Manassa: Yes. It's not virulent. It's it's, delta was probably a lot more virulent. And that was probably one of the more virulent forms that we've seen of SARS-CoV-2 that that one was scary because it was it was the most transmissible to date, but it was also very virulent. So now we're like tipping the scale. It's very transmissible, very, very transmissible, but becoming losing legs in terms of virulence.

Henry: So OK, so it's so I’d like to go back to something you said earlier. So whether you're following the news you're seeing these. I'm just going to say and please correct me if I'm wrong about this, you're following the news. You're seeing China locked down a city. You're seeing them build field hospitals. Right. You're seeing numbers that are not good, correct.

And then you see a case in New York. You understand the doubling time is not good.

So can you tell me about how you're personally feeling around that time?

Manassa: Yeah, I would. I had a “put me in there coach” mentality. I'll never forget it. We had a meeting we had a divisional meeting and certain people were kind of identified to do certain things, to lead certain responses. That was kind of within their job description. And at the time, it wasn't really in my job description, but I just so eagerly wanted to be at that. I wanted to run in that burning building.

And so I found my own damn way. I was not waiting for anyone's permission or anyone to give me the green light to say yes, go in, in there and help. I found my I maneuvered my own way. I remember that very, very distinctly.

Henry: And this meeting occurred in January March.

Manassa: This meeting was like, I want to say it was like late January or early February.

Henry: That’s early.

Manassa: That’s early. Yeah. Because, you know, we were the group of people that were watching and learning and we we always kind of at the infectious diseases section of our hospital is always the group that is tasked with learning the stuff first and then kind of interpreting it for the rest of the hospital to kind of help them wrap their minds around the threat level.

Henry: So million dollar question, why do you think so many people did not understand the threat level?

Manassa: So much of it, so much of it is not only is it a threat to their wellbeing, but it's a threat to their way of life. And there's a certain... OK, I'm not an expert in this, OK? This is just my observation through all these different waves when it's a threat to their way of life and their comforts and their perception of themselves, they don't want to they don't want to go there they're there's a certain fear and denial to reckon with the fact that things are going to be heavily disrupted for an unknown period of time.

So I would say that that is kind of pervasive. However, the flip side of that is that once the threat became I'm sorry to Bruce, I'll call them back. Once the threat became very real and apparent, it went from theoretic to here and now people share that very, very quickly mobilized and everybody it felt like for a golden couple of weeks, everyone was moving as one on the same page.

But it takes a lot to get to that point. I didn't you know, fast forward a little bit later, you know, my I forgot a lot about 2020. I forgot a lot. You're jogging it for me. But otherwise it's weird. I like put this stuff far away or I filled it with so much other garbage that I don't remember this stuff anymore.

So for me, my framework for the, for the pandemic is 2022 where we had another surge that to me felt so much like 2020, just in the numbers, just in the sheer volume that we were seeing in the hospital, outside the hospital, how busy I was, how how all consuming the pandemic became again to me those two periods of time were kind of similar.

And I feel that the denial component that this won't be that bad. Oh, there's no way it can be as bad as then, like that was strong, that was heavy. Until it was a reality again. Then of course, people quickly put those things back into place and we did, we did it. We got that one down very, very quickly.

But that initial denial about how bad this can get, that's pretty powerful. And I've seen it play out multiple times.

Henry: OK, so most- All right. So that was just a few questions to wrap up because we're getting up there in time. so most of what you've told me about this response has been in terms of your professional response and your organization's response when you were seeing these numbers coming in did you change your personal behavior at all?

Manassa: Oh, yeah. Yeah. I mean, you know, we locked down our family. We sent the kids out to my parents house, all the elderly. We basically cohorted, the whole family. We told them no. We told them don't do anything unless we say it's OK. We as the health care workers in the family. Yeah, my kids were remote for more than a year.

Definitely made a lot of personal changes. You know, we're still wearing, we're still in masks because transmission is once again very heavy in the community. And yeah, for sure, for sure. Made made a lot of changes. But we feel good like we we feel OK with we don't feel that we've made excess sacrifices to get through this pandemic.

We are perfectly happy living with masks for however long it takes. If it means my kids can go to school, my mother in law can go to the grocery store, my you know, whatever, that that's normalcy for us. The mask thing is our ticket to normalcy. So in that way, we don't we don't feel significantly put out by this thing.

You know, it has totally hundred thousand percent altered my career and there's been so many. It's been a really interesting journey. Like now I'm trying to divorce myself from it because I invested so much. But now no one cares about this disease in the same way. It doesn't mean the same to them. It's a test. They want to move on so badly.

So for me, it's like, why would I put all my eggs back in that in that basket when it's something that exceedingly people are are not giving a crap about anymore. And so my revolution was like really interesting.

Henry: That's a good point. And to be honest, I was very like, I don't I do not really want to do my thesis on COVID. I but I figured that the focusing it on the pre crisis period would have implications for other slow onset crises or other creeping crises like whatever famine is.

Manassa: Oh yeah. Oh yeah.

Henry: I'm sure there will be a famine that hits the West to some point. So what cognitive biases are we going to be seeing in the few months preceding it that prevent effective action?

Manassa: Right. So on that note, you know, the slow burn crisis that I was dealing with before, and I’d like to go back to dealing with, is antimicrobial resistance. And so that seems like it's going to be this is definitely exacerbated by all this. But something like, you know, 50 million people would have suffered an antibiotic resistant infection within a few decades.

So that's that's that crisis will ultimately exceed COVID, but it would be over a much longer timeframe where it's not as urgent to people. Unfortunately.

Henry: We'll see.

Manassa: Yeah, we'll see until they have it.

Henry: About the time frame. OK, also. Yeah, it's interesting that you said that you don't remember that much in 2020 because the original idea for this, I mean, you know in these interviews are not perfect. Ideally I'd be using contemporary writings and contemporary messages. I really wanted to do diary entries, but the data collection was too hard. OK, anything. What else would you like to tell me about the way you felt in early 2020.

Manassa: Oh I was ready to jump in whatever it required I was ready to do whatever was needed for my organization.

Henry: Any panic, dread, anxiety.

Manassa: It was a dread. There was a dread. Not before, not before. During. Before. I was just sort of very interested, extremely in I wanted to consume everything there was to know about this disease because you know, stuff like this is why some of us chose to do this, this particular field. But the dread certainly, as I would say, late March, early April when we were hitting our peak.

Oh, man, that was not that was not far because I felt like just everyone was looking to me for answers that I didn't have. So just that kind of let down aspect was definitely something not terribly fun back then. But leading up to it. No, I was just very plugged in, very interested in the disease and understanding as much as I could at the time about it.

Henry: What do you think? I should have asked about that I didn’t?

Manassa: Specifically that pre immediate pre-pandemic period maybe like what did you think? How did you think it would play out or what did you expect to see and what did you actually see.

Henry: So what did you expect to see?

Manassa: I thought, you know, I thought it would be like, OK, a couple of dozen cases, we'll figure it out. We'll figure out how to kind of shut this down.

I didn't think it was I was I was making the parallel in my head to flu. Honestly, so we actually exceeded that, to say the least. And maybe how did you how long did did you think this would go on for? Because I'm sure that nobody thought year number three. And how did you think this would end? That's that would be interesting because no one really knows.

But I didn't think it would end. You know, I didn't expect now that I would be a fan, that that my I would feel like I'm on a sinking ship. And I’ve like, you know, put banked my entire career on this thing that now nobody and everyone is trying to get as far away from as possible. That's kind of where I'm at right now.

Henry: I think all the people who made the livings writing about the Iraq war, right?

Manassa: Yeah.

Henry: Academically, that's what it feels like. You know, when you read about those.

Manassa: Interesting. Has anyone like made that parallel was is that are people starting to kind of write about this kind of abandonment phenomenon?

Henry: Oh, abandonment. That's a good word.

I've not I don't think so. Actually, the historical parallel I'm working off of is the onset to World War One. Aside from the other pandemic ones, because that's also relatively similar time frame you know, organizational decisions, organizational and government level decisions being the ones that matter. So that that's my historical parallel with the abandonment is I mean, I make the parallel more in terms of tone.

Sure, but OK. Is there anything else you'd like to tell me?

Manassa: No, I think I think that's it.

Henry: OK, again, thank you so much for helping me with I may have some some follow up questions for you at some point, if that's OK.

Manassa: Sure. Are you speaking with other people in our organization or did you need additional folks?

Henry: I'm always looking for additional folks. If you have any who you think you would like to talk with me? I've spoken with quite a few people in your organization at this point. It doesn't need to be. It's not my data is not a representative sample at this point. But so if you have anyone else who you think would like to talk with me, please please let me know or ask them and I'll contact them.