Interviewer(s): Henry
Interviewee(s): Charles

Henry: Thank you. Your real name will not be used and any references to the organization will be alluded to. I have some questions, but if you have something off the top of your head, then great.

Charles: So. So in medicine, with influenza, as an example about every 20 years we had a pandemic and starting in the eighties we were overdue for a pandemic. And the older physicians would ring the bell, we're going to have a pandemic, we're going to have a pandemic. And then a year would go by, five years go by, ten years would go by.

And guess what? We really haven't had a influenza pandemic to the extent that we used to. So if you think about some of the big ones like the Spanish flu in 1918, which killed more people than some of our global conflicts, you know we became I think a little complacent in terms of OK well some of these big fears are not going to come to fruition The other thing that's really important is that we've seen some incredible threats that were mitigated that did not turn out to be pandemic.

So you have the first SARS and that was really incredibly well controlled and it did not spread and our standard approaches to isolation and quarantine and tracing were enough to halt that from progressing and that was a highly lethal disease. MERS, another type of similar disease did not become a global threat. So I think there was some complacency in terms of, OK, while the US did fine with these other threats and we also had Ebola and we put a tremendous amount of infrastructure in, we here built an Ebola unit and you know, no patients ended up coming.

We controlled this potentially lethal global threat through our standard approaches to quarantine and vigilance. When we saw what was happening with this new coronavirus a lot of it I think was OK, well, China's infrastructure is really poor and they're not doing a great job and there's a lot of secrecy. And so we don't know enough about what's happening there, but as long as we maintain our vigilance at our borders and as long as we are quarantining people who are febrile and they're traveling, you know, we should be able to mitigate control.

This because it hasn't jumped from place to place really, really quickly. And then where to go, it went to, for example, places like Thailand. Well, the Thailand's infrastructure is really poor, so why wouldn't it spread in Thailand when they don't have all the sophistication that we have here? In the States and other highly developed areas?

The other concern, which really wasn't addressed for several weeks into the March, April pandemic, was, you know, what type of mask do you need to wear? Do you need to wear a mask at all? And then, you know, we got to the point where you needed to wear N95s and face shields fairly quickly so that the lack of understanding about transmission, the expectation that this was similar to other coronavirus is and other, you know, influenza type of viruses in terms of its mode of transmission.

So there was an under appreciation for how it got from person to person, which allowed for its ongoing spread. When, when we saw this happening in Seattle, we in New York were very, very concerned. And we started talking about what would we have to do with our students. And we took our students out of the classrooms. We stopped doing our clinical skills activities where it's fake patients.

We continued our students in the hospital and then on March 15th for a variety of reasons, particularly because of the really rapid, rapid rise of cases in our hospitals. Again, on on the beginning of March, we had none. Then a few days later we had one and we had 20, then we had hundreds, and we maxed out at just under 2000 in our hospitals when our normal capacity is far below that.

And at the same time we were burning through protected equipment. And so the governor said, you know, only those who are absolutely necessary in the hospitals should be there, and a medical student is not necessarily essential in the hospital. And our health system was running out of masks and gloves and gowns and so on. The 15th we pulled our students out and interestingly across the country, students were pulled from hospitals, and that was something that the WAMC, the Association, American Medical Colleges made as a statement.

I was very conflicted with that because as a learner, being in that situation as long as it's safe is incredible. Also, I trained in the time of HIV when we had no drugs that worked for HIV. And just being in with patients and even just consoling or talking to them was transformative for those patients and for some of the families. And that was a huge crisis here, is that we had no good therapeutic approaches and we didn't really have any drugs that were effective early on.

We are still learning when to give steroids, for example, early, late, never whatever. And we actually put our students back in on March 30th. We are the first school to put our students back into the hospitals, and we did it on a volunteer basis and we did it with our senior students first and the regular students we didn't put back in until June.

So there really was a delay from those who were not already highly skilled to those who were skilled going in. And again, part of that was you need to have supervision and there weren't enough doctors or residents to supervise, because so many were sick and we had so many people. So we had to do it in a targeted fashion.

Henry: Right. OK. So you said that there was this underestimation of the issue, though, correct? There was this underestimation of the virus in these first weeks. Why do you think that underestimation persisted?

Charles: Well, it depends where you're talking. So at a place like our hospital, there was no underestimation. We we were in a, in a life and death fight from very early in March, other places.

Henry: OK, but like January, maybe.

Charles: Well, again, because in January, we hadn't we hadn't we hadn't seen any in the States and the CDC wasn't allowed into China. And so we weren't able to get a lot of information. There was a lot of uncertainty as to what was going on. And I think it was really only later that that a lot of images and data from Wuhan and other places became more available.

So so again, obfuscation was was a challenge there. And it's also hubris we are we are a well-developed place. We have plenty of ventilators and we will be able to to combat this. We've we've overcome other challenges and we have these procedures and policies in place. And we should be fine.

Henry: Yeah. So when that gets into an issue of scale, though, no?

Charles: So so absolutely. Gets into an issue of scale, but it also gets into an issue of community and not necessarily just health system. So why why, for example, did the Bronx get hit so hard and Scarsdale and Larchmont not? So if if somebody got sick in a 5000 square foot house and they had to stay in their own room and they had their own bathroom.

Well, that's easy. If you're in many of our communities here in the Bronx, where you have multigenerational households. So you have a whole bunch of kids. You have the wife and the husband and the sister and her husband and one or two sets of grandparents and maybe an aunt in the house. You know, that entire house gets COVID, and the grandparents will die.

So it's it's it's not just what we're doing in the health care setting. It's what was happening in our communities. And it wasn't just what we would say. So there were, for example, Orthodox Jewish communities that totally didn't and still don't follow a lot of common sense types of behaviors about, you know, staying home when you're not feeling well.

And so it was what we thought people would do, people did not necessarily do. And even when we said, oh, jeepers, people should wear masks, you have seen where that has gone. So there's only so much you can do in a fairly open society. Look at what's happening in Shanghai right now. They've locked down the city. That is that is not something that we can do.

And the states, you know, a lot of what happened, happened because of human behavior. And that's unfortunate.

Henry: Yeah. Well, we don't yeah. I don't know. We never had the capacity to lock down like they did. “ike our government I don't think our government had that has that capability. But I mean, you mentioned community earlier in your community characteristics. When can you tell me about when you realized that would be a problem.

Charles: We realized, well, it was it was really within the first weeks of our experience that we saw this. And I don't remember that being so much commented on and the process with Seattle. And again, you know, sometimes when you're in a firefight, you don't necessarily pay attention to everything or what you're sharing is not shared in a way that that translates into an understanding of of what some of the challenges are.

And I think it was really very early on because we saw, you know, families coming in to the hospital. We had several situations where we put spouses in the same room. We put daughters and mothers in the same room. And, you know, it was really a family, a family disease in some ways. And again, that was not the case in many parts of the country where you didn't have people living in those in those closed spaces.

And it was March. So it was still cold. So people weren't outside the same way they are in the summertime and you're not opening your windows. And so it just it just was a factory of of closed viruses getting generated and spreading across the families.

Henry: Right. Well, you've actually touched on something that I think is very important to this project, which is how the information translates into action. And if it doesn't translate into action, what prevents it from doing so?

Charles: So one thing that I do think is interesting is as opposed to other types of infections, it wasn't that there was a lack of ability to get medication for the infection because there were no medications so it wasn't a disparity in terms of, you know, someone being able to afford a very expensive cholesterol lowering medication versus not being able to afford that, which if you look at other pandemics like diabetes go into, can you afford the insulin or not?

And so or with needing an EpiPen and being able to afford the couple hundred dollar EpiPen or not. So even though this was an epidemic that really adversely impact those more marginalized, it wasn't really because they couldn't get medications to for their disease. There just were none. And again, the government has made all the vaccines free and the testing free.

And so that that has broken down some of the structural determinants that have dramatically impacted other, you know, diseases in our country adversely. And so that that mitigates it a bit.

Henry: Right thank you.

OK, just so just some basic questions for a sec. What was your position in January 2020?.

Charles: And January 2020? [Position details] I basically run the medical school.

Henry: OK, and how old are you?

Charles: I am [mid 50s].

Henry: OK, great. Thanks.

Charles: One of the other things, you know, I'm an infectious disease doctor. So when this all happened, I became a de facto COVID czar for the institution and I continue to do that. So I just got an email, for example, about a student who was accepted to our program but hasn't been vaccinated for COVID 19 and she has an exemption letter.

And would we accept her exemption letter? So I had to read that and respond. So that's still ongoing. So we all did multiple different jobs and I did some patient care. Initially it was through electronic consults because I was so busy over here. But on nights and weekends I did some of those. And then in I think it was June, I finally was able to carve out some time to do patient care during one of our surgeries.

So but Henry, if you have other questions after this, please feel free to shoot me an email and I can try and answer additional questions for you.

Henry: Oh, sure. Yeah. Thank you. I mean, do you have, like, a very strict time limit here?

Charles: No, I have I have at least another 10 minutes.

Henry: OK, great. Yeah, I probably will have follow up questions. At some point. And just I speak with my advisor tomorrow so I can see mentioned. I mean, we're still in it.

And it seems like this duration has taken a lot of people by surprise. Why do you think that is?

Charles: Well, first of all, most pandemics don't last this long. They they burn out this this virus has continued to evolve. That's been one of the challenges. People haven't really followed instructions and even within the US, we've had very disparate responses in our different states. You know, New York has been very active and proactive and then places like Florida have been, yeah, it's fine.

So you have excess deaths in Florida relative to New York. In terms of how communities have addressed this, there are communities where vaccine rates are low and you have communities where vaccine rates are very high and mortality rates are linked to those. Unfortunately, there's also an association with being a Democrat or a Republican in those areas. And so the divisiveness of politics has has really adversely impacted our response in this country and Brazil and other places and incredibly so you look at someplace like North Korea when quote unquote, they have a big fever problem and they're very under vaccinated.

Almost no one is vaccinated. We've tried to send vaccines there and they haven't been receptive to getting them and now they have deaths and it's probably massively underreported. And. Well, North Korea is a breeding ground for another emergent variant. It's highly possible. And so we continue to have petri dishes of populations that are churning out new variants. the vaccines are very good, but they're not long lived.

And that's a challenge, too. And people don't want to get a vaccine and they certainly don't want to get to and they certainly don't want to have three. And they certainly don't want to have four. And so that's been a challenge as well. And no one wants to wear a mask anymore.

Henry: I mean, is this how you expected things to play out?

Charles: Early on, no, I expected it to kind of ravage through and burn out because that's how we've seen other other viruses like this.

It's really surprising how this one has dragged on. However, after about six months, many of us said this is not going away. We're going to be in this same place. And when I I've been in leadership at the Infectious Disease Society of America, and [PII omitted] And when it was remote in 2020 people were saying, oh, we'll be live in person next year. And I said, no way, we're not to be live in person next year and.

Henry: Next year in Jerusalem.

Charles: For 2022 it will be in person and it will be in person because we now know what you need to do. I was at a meeting for the European Infectious Disease Group about three weeks ago and they had 11,000 people there. But you were mandated to wear a mask inside, and everyone was wearing it and believe it or not they're wearing it correctly, not as a diaper or something like that.

So I think, you know, if you're able to, to do these and have a responsible group, you can have large meetings. But I just was on a flight back from Florida. [PII omitted] and on the flight back, my wife, my, my son and myself and probably four or five others were the only ones wearing masks on the entire plane.

So, you know, people are done with this and that is going to lead to this continuing to smolder for some time to come. We are in a surge right now. Fortunately, the lethality has reduced. We're still seeing deaths, but most of the people are older immunocompromised or haven't been vaccinated.

Henry: But I'm sorry to change subjects. You're actually the first person to bring up Seattle. OK, so just real quick, can you tell me about just first, when you first heard about COVID?

Charles: It was it was definitely December of 2019 at the at the latest I mean I heard about it very early. I get these notifications and I was going to Thailand in the middle of January and there was a lot of discussion about whether I should go there or not for this visiting professorship. And I was flying through Taiwan.

I was originally supposed to fly through Shanghai and so I didn't want to fly through the mainland because that's where they had this virus. And while I was in Thailand was when they had the first case in Bangkok, I was in Chiang Mai and I watched over the week that I was there. Now a lot of people do wear masks in Thailand because of the pollution, but by the end of the week, almost, you know, 80% of people were wearing masks because they were all sure it was coming and when I came back, I said, you know, this is spreading and we need to be vigilant.

And we we had I think we were more proactive at [organization] than than many of our sister [organizations]. We had a lot of plans in place, you know, “if this than what?” And you know, over the week of the seventh to the 15th, we had multiple daily conversations about, you know, when we were going to pull which students out of our health care system do.

Henry: Do you think that being in Thailand or being in Bangkok and seeing all the people in masks, do you think that influenced your perception at all?

Charles: I do.

It definitely made it more real. And again, some of the news coverage, there was a little different than the news coverage here in the States.

You know, when I flew back through Hong Kong, not through Hong Kong, through Taiwan, you know, in the airport on the way out, there were a few people wearing masks on the way back, about 50 plus percent of people wearing masks. You know, the idea of having to wear a mask was, I think, much more stimulated because of what I saw.

And again, as as an infectious disease person wearing masks and being in the hospital wearing masks, you know, I'm often the one called to go into a room with someone who might have tuberculosis or something else. And so I'm very comfortable putting on masks and wearing masks for a longer period of time. So, you know, I, I was a very early proponent for wearing a mask.

In fact, even though masks weren't fully suggested for people in the community, we put a mask mandate on earlier than many places. We kept our mask mandate on longer. When our mask mandate was removed, I argued against it. I re-instilled the mandate in our classrooms because I have control over that facet of the institution. And then about three weeks later, we reinstituted our mask mandate.

And then when we removed it again a few months ago, I made sure that the language was that because the first time it was written, you know, you no longer have to wear masks. I'm like, No, it should be masks are not mandatory. However, you know, please continue to wear them if you feel. Yeah. So there's very different messaging how you say something.

Henry: Right OK, should you get back from when you get back from Thailand, Taiwan, and then you see it hit Seattle, right? So what are you thinking at that point?

Charles: I'm thinking it's coming here next. You know, there's, there's there's no way it's not you know, if it had gone to let's say, you know, South Dakota, where they have very poor infrastructure and they had a hard time managing it I would have said, well, they don't they're not heavily resourced. But, you know, Seattle is one of the premier health facility centers.

You know, they're they're incredibly well resourced. There's tremendous public health in Washington State. And watching how they have this cascade of challenges and again, they pulled their students out.

Henry: But I mean, if but if it made it to South Dakota, it would surely be in New York as well.

Charles: But, you know, the traffic between Seattle and New York is is is very high. The traffic between South Dakota and New York is not not that high.

Henry: Well, same with Wuhan to South Dakota is not that high either.

Charles: Well, you know, but again, Wuhan is a major urban setting so my my point is that if if Washington State, with their incredible public health and the remarkable health care facilities that they have, was not able to handle this very effectively we then, you know, New York is usually the next place to get something. So if if drug resistant gonorrhea is in San Francisco and L.A., guess what?

It's going to be in New York very soon too. HIV, you know, L.A., San Francisco, New York. This is just how you see it. And so I was very confident that we are going to have this. How much of a challenge it was going to be wasn't necessarily clear yet. Again, at that time, it was thought that this was droplet spread, and droplets are much easier to manage than aerosol spread.

And so we thought we had better tools and we thought we knew more early on. Then than we did.

Henry: Thank you for that.

Last one, because you got to go see Seattle, Bangkok, Seattle, Iran, Italy can tell me about how you're feeling.

Charles: So it is complicated because again, this is something that I had I had worked toward and trained toward, to be able to participate and engage and lead an infectious crisis. And so it was tragic. You know, the numbers of people that we were able to save was incredible. But the number of people that died during that March, April or early May was was devastating.

You know, we we had trucks of bodies at our institution and that's just devastating. But I was also incredibly energized and and just overwhelmed by the actions of my peers.

You know, that there are some you know, it's hard it's hard to really get a sense of what was going on there in our health system. But there are actually two videos. One was on CBS, CBS, I think it was called In the Hot Zone. And that was like an hour long special and then there was another one in The New York Times that was shorter, about a 12 or 15 minute video.

Both of our hour emergency departments and how incredibly busy they are. They were and just how you couldn't have family members present. So, you know, people were dying alone. And so, you know, going in and just holding people's hands and finding a way with your iPhone or iPad or other phone to face time or Skype or whatever so people could say goodbye.

And you're talking about you know, 30 year olds and 40 year olds, not just nine year olds who are dying. And so it just it just the heroism when, you know, facing something that we really didn't understand and had no good therapeutics for and how hard people were working and how creative people were and figuring out just simple things like turning someone on to their stomach that is called proning, change the physiology of the lung such that they were able to have better expansion and maybe didn't have to go on a respirator because once they went on a respirator, they had more trauma to their lungs from that pressure that's exerted on them than regular

breathing. And so you know, early on, we put lots of people on ventilators very early, and now we try everything we can to keep them off a ventilator if they have COVID 19, because we know that is something that exacerbates the trauma and inflammation of the lungs. So we put them on these multiple masks and have air flowing and all different ways.

So just it was it was incredibly inspiring. And again, I, I, I was working 16, 18 hours a day, seven days a week for four months to try and keep our students doing things that would keep them going in their curriculum and to make sure [organization] was still functioning. Many places closed, many places killed all of their mice because they didn't have, we, we never closed, we downsized.

We said only essential people we set up some rotations for people to come into labs. So only one or three students would be in a lab at a time instead of 12 or 15 and there just was tremendous amount of of activities. And it was exhausting. It was terrifying for patients. It was terrifying. For some of our colleagues.

[PII removed - wife is specialist doctor] and she ended up running an ICU for several weeks. That was an expansion ICU because someone had to do it. And she worked, you know, 12 hour shifts and then did ten hour shifts on a COVID floor for another several weeks. And she has still PTSD from, from that because it was stuff that you never expected to see or do.

And, you know, someone had to do it and do it as well as possible. We're fortunate now. We have different drugs, different therapeutics, and, you know, mortality rate is down for a variety of reasons, including our newer drugs. But it was it was it was like being in a war zone the early days.

Henry: OK.

Charles: All right. I have I have to go.

Henry: Thank you very much. That was tremendously helpful.

Charles: I'm happy to answer some other questions by email and stuff as we move forward.

Henry: Great. Again, thank you so much.