WAMC Podcasts
WAMC Podcasts
WAMC News Podcast - Episode 104
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On this episode, we get a coronavirus update from Dr. Andy Coates of Albany Medical Center.

Oh, well, thank you very much, Ian, for having me. I would say that the curve is indeed bent. There’s a flattening of the number of cases. The cases are still coming in Albany, they’re coming rather slowly, but still coming. The cases have been actually counterbalanced by discharges and sad to say a few deaths. There’s still a preponderance of COVID-19 pneumonia in the intensive care unit, but nowhere near as many as before. Before of course though the intensive care units were full because of the crisis that happened in Queens and the need to urgently transfer as many patients as possible to other hospitals and Albany Med took to quite a quite a volume. And incidentally, some of those patients are still admitted to Albany Med. The character of the hospital is still that odd quiet where visitors are not allowed. We don’t have the quite the census that we usually have. It’s usually very bustling place. By comparison, there are some units that were readied to be expanded into emergency intensive care units, units that were ordinarily floor units, but then were adapted to become intensive care units in case there was a surge so the hospital was retrofitted to run at 150% of capacity and With the census down from normal, and the hospital revved up like that you have the feeling that there are some empty places. There’s still plenty of normal medicine but not the volume we would normally see. So the character of the building is a little bit odd.

You know, we have a story today by Paul Tuthill in our Pioneer Valley, bureau about that very issue in the state of Massachusetts. And in his coverage area, there’s a lot of concern that people are letting stuff slide because they’re afraid to go into a hospital right now. They are worried about catching coronavirus, but they have a more pressing medical issue that’s going unaddressed and there was one study that showed even parents had kids with a ruptured appendix, maybe didn’t bring their kids in fast enough. So what’s your advice to people? How should they make a calculation right now about whether to seek care?

I think so. Anyone who feels that they’re having a medical emergency should act just like they would have before COVID-19 and call 911 and come into the emergency department. If you think you’re having a medical emergency, you may in fact be having a medical emergency. The cardiology, one of the prominent cardiology journals published an article that showed that it looked like acute myocardial infarction presentations were down at one hospital by as much as 38%. We wouldn’t expect myocardial infarctions, as they generally occur in society, we wouldn’t expect this pandemic to change that number.

In other words, heart attacks aren’t going to be down by 38%.

Right. And so what we fear is that presentations of heart attacks are down by 38% and the patients may be doing poorly at home. I saw in the Times Union that there were five patients who lived in isolation and Rensselaer County who were found dead in their homes, five different patients. There’s no details about their medical illness, you know, appropriately, but you worry one worries that there was an untreated pneumonia, an untreated stroke, an untreated heart attack, not a COVID-19 illness necessarily. The hospital by now, you know, many weeks into COVID-19 patients, six weeks in, the hospital has become extremely adept at personal protective equipment, isolation rooms, that’s separating patients, the consciousness of hand hygiene, the consciousness of spatial distancing, all of the things that would prevent the transmission of the virus are paid keen attention to by every staff member. From the janitorial staff to the very leadership of the hospital, the entire hospital has a consciousness of not spreading this virus. So if you have an acute symptom and you think you need acute care, please present to the emergency department just like you think you should. The doctors and nurses are there and they’re ready for you.

We are hearing a lot about the need to ramp up testing. Governor Cuomo has been talking about this. We have these early, you know, first 19 different areas where there was testing for COVID antibodies. What does that show us? What do those tests show us that helps us with understanding the spread and the containment of this virus.

So I think the COVID-19 pandemic has caused me to read a fair amount about the history of viruses and the history of medicine. And the response to viruses. It seems to me that in pandemic planning, that is pretty well documented within the last 20 years, that if you knew there was going to be a potentially pandemic virus, and it looked like it was really taking off, you might think about the utility of testing immediately. Can we have a rapid test that identifies people who are acutely infected? Then can we have another test that identifies people who have been infected, antibodies that the immune system is developed to fight the virus off? Very well established that if your body’s acutely responding to the virus, you may have immunoglobulin M antibodies and if you’re developed to have more thoroughgoing immunity, longer term immunity, antibody to that, an IgM antibody. So antibodies, IgA, IgM, and IgD to the virus, but then there’s deeper things to understand as well. Because of the polymerase chain reaction, we can now look into the blood and see the viral load. How many circulating RNA molecules of the virus itself are in the bloodstream, might be asked how many and then we can do quantitative antibodies. How many IgM antibodies will convince us that the patient’s going to be safe from a virus, you know, a viral attack? When the IgG antibodies are sufficient, can we be confident that the patient is now fully immune to reinfection? Can we understand all of that? Testing could tell us so much, and all of this testing that I’m mentioning, the polymerase chain reaction tests, the swab the nasal swab, or the oral pharyngeal swab, which can be turned around in a few hours in modern medicine, and it’s really something and a big advance and the older antibody tests, these are all very well established medical tests for other viruses. And so, it seems to me that if this particular infection had been taken seriously as a pandemic, at the time that many astute world leaders were saying it was a pandemic, there should have then been a rush, an absolute rush to create testing capacity so that so that we could know where the virus is. And for the patients who have it, whether or not they’re getting better or worse, or whether their body already cleared the virus. So there would be a way through developing all of these tests. Now it’s the novel coronavirus SARS-CoV-2. So this is SARS-2. Earlier there was SARS-1, which went to many countries, and there was also the MERS virus, the Middle Eastern Respiratory Syndrome that was also a coronavirus. All of the fact that it’s a novel virus means that the what antibodies the body is going to make, and when they’re sufficient, and how the body clears the virus when to know you’re better when to know your immune, all of that has to be worked out in in real medical time and that that’s not going to take place by magic. That’s going to take place by going and doing studies on people who are infected and developing all that testing. The United States of America chose to let private companies develop tests because of the belief that the profit motive would incentivize individual entrepreneurs to find the test. And that may be in fact, what eventually happens and that certain laboratories that patent the test that New York State and the hospitals buy, can build in a hefty profit margin and get very wealthy from the pandemic. On the other hand, we see the government literally spending trillions of dollars to make sure that the banks that are too big to fail, don’t fail again.

I think it was heading towards $7 trillion in federal financing of different forms. So certainly the resources in the society would have been there to make the decision to build a massive testing capacity and I think I daresay the resources of the United States of America are still sufficient to build a massive testing capacity. That testing then would give us a way to know where the virus is exactly how to contain it, and, importantly, when people are over it, and if we were to begin to develop a vaccine, a way to know immediately that people were immune. So testing goes hand in hand with getting control over the virus. And it’s even amplified more by the fact that we don’t have good pharmaceutical treatments. We don’t have proven pharmaceutical treatments.

Why is that?

Well, it’s a novel virus, it’s a novel coronavirus that found its way around the immune system. Antiviral medications are very, very difficult. The fact that the antiviral medications that work so well against HIV works so well is a major accomplishment of modern science, a major molecular, genetic even on the level of molecular evolution, a very, very big accomplishment of modern medical science. And so that’s not something that can happen lickety-split or magically. The idea that hydroxychloroquine may or may not have an impact because it was used as against malaria, was used against some other viruses, the idea that remdesivir, which is an antiviral drug that didn’t work against Ebola but is trying to find a place now. You know, there are some drugs that have no really good randomized control trial evidence, but we have a culture where we want to try to do something. So I think the short answer to your question is, it’s a novel virus that to which we don’t have herd immunity, and to create a pharmaceutical treatment would require experience with the virus. Since it’s ambushed our, gotten around our immune system, we have to understand all of that immunologic response before we can disrupt it with a drug. And that takes time and that would take some scientific understanding. Although I suppose it in terms of treatment, I might talk here about convalescent plasma.

Please do.

Okay. So, at Albany Medical Center, I understand that at least more than a couple of dozen patients, I don’t know today’s count number, But as many patients as we can, we’ve been able to do in a very, very hurried up way over the last couple of weeks, have received convalescent plasma for passive immunity. And this this is very interesting. the outbreak of the measles over 100 years ago, was met with the observations of physicians that newborn babies whose mothers had had the measles didn’t seem to get the measles and that, that there must be something special about people who got the measles and got all better quickly. And the idea became maybe within the bloodstream of those who had the measles and got better, there are antibodies or something, but turned out to be antibodies to the measles that would help a person who’s acutely infected. And so, passive immunity against the measles could be provided by taking the convalescent serum. That means someone who’s already had measles and is now convalesced, taking the convalescent blood from someone who is now better and giving it, a dose of it, to someone who is acutely infected. And in fact it had great impact. It also taught medicine an awful lot about other things, like serum sickness, because it didn’t, of course, help everyone and also hurt some patients. If a patient can be cross matched blood type wise with a recipient, and their plasma can be plasma free, so we’re just taking out the antibodies and the molecules that might fight the virus as much as possible and then that can be given to a patient who is acutely infected. This is a very old treatment, I believe the very first Nobel Prize in Medicine was awarded around convalescent plasma, and that’s over 100 years ago. So I, I think that that this idea actually holds genuine promise and I’m proud to be part of an institution that will be contributing to the international literature about using passive immunity. In the modern pandemic.

So the question that I have to follow up on that is, we’ve read that something like, you know, nine out of ten people who goes on a respirator suffering from coronavirus doesn’t come off it, very grim numbers. That sounds like it’s a separate issue from the public health issue of testing, finding out where the disease is, you know, controlling the spread. Is what you’re talking about something that could be applied to patients who are in an emergency situation, or are we talking about getting toward a vaccine or something like that? Do you understand my question?

I do. So, in the short run, the answer is yes. If we could understand how to obtain and use convalescent plasma and the antibodies from patients who have recovered from coronavirus from SARS-CoV-2.  COVID-19. By the way, you know the name of the virus starts CoV-2 and then name of the infection is COVID-19. Just like HIV is the name of the virus and AIDS was the syndrome when people got very, very sick, sick from it. So COVID-19 infection, when it’s acute if we could give a measure of, of passive immunity, the immunity from some other patient, not antibodies that your body made, and they could fight that virus and temporize that virus because they were in your bloodstream or my bloodstream for a little while as the virus was coming in. Then yes, I think that all the treatments of all the pharmaceutical and interventional treatments besides supportive care, which is to just you know, try to keep the oxygen levels up as long as possible and by any means necessary. Use a ventilator. Use whatever you have, in other words, best supportive care and the body will take care of it itself. I think passive immunity right now holds some promise and is and I wholly support its investigation and its investigative use. So yeah, the public health measures, though, are on the other hand, the non-pharmaceutical interventions, those are proven to work and that’s really all we’ve got that’s proven.

And I’ve heard a lot of people talk about the need to establish what South Korea has done. You were talking about this in our last conversation, you know, contact tracing. We already have phones, following our every movement. So it might be possible to say, okay, you know, there’s an outbreak in x city. No one can come and go from there until we’ve got this, you know, sort of in control. But the last time we talked to you, I asked you when you thought that we’d be back to something approximating normal and you said fall of 2021 Do you still feel that way?

Well, I think that was as good a guess as anybody’s gonna give right now. I don’t I mean, if there’s a vaccine and there’s a mass produced vaccine, I suppose that’s right. The social distancing, as it’s called here, the spatial distancing. I’ve been looking at that a little bit. I got quite excited by a New York Times article about this question that led me to delve into the medical literature myself deeper. It seems that George W. Bush read a book about pandemic flu. And he had, you know, he presided over some, some genuine crises, right. So, with his consciousness raised by this book, he asked for people to make a pandemic plan and he got some doctors who are creative thinkers. And they looked back all the way to the plague, to the 14th century, and found that self-isolation and spatial isolation and staying far away from one another, was actually effective at stopping transmission. One of the things in that article that’s fascinating is that there was a 14 year-old student, the daughter of a Sandia National Laboratories leader, who had written a science project modeling report on social networks among school kids. And the conclusion that they took from her model of how viruses might be transmitted amongst school kids was that by simply closing schools, communities had a measure of protection from the spread of a pandemic. And they wrote that into their pandemic plan. And then there’s a marvelous World Health Organization working group paper, I think about a year later about the same coming out of the same thrust of pandemic planning. So this is 2006-ish. And what that paper lead me to was a very deep dive into the 1918 influenza pandemic. And again, spatial distancing, social isolation, a good understanding of how the virus might be spread, hand hygiene, face masks, all of these things are actually saving lives, actually saving lives.

So not what Georgia is doing as we speak tonight, reopening bowling alleys, salons tattoo parlors. That seems to be a bad idea.

It’s well, it’s very distressing. It’s extremely distressing because the way that our society has organized, the most vulnerable in our society tend to be those who really have no choice about the social conditions that they live in. Think of those confined to the prisons. There’s no way to prevent a pandemic from galloping through a prison, the way the prison is organized. There’s no way I dare say that all of the infection control measures that a nursing home might try to employ, it’s extremely difficult for a nursing home patient to protect themselves as best as possible because of the way that the nursing homes are organized and run and so and so it goes for the poor. You know, I think we talked about this as well, if there are many people sharing one toilet, one bathroom it’s extremely difficult to think about some kind of internal quarantine in which one of the many people in the household is ill and the others are not going to be exposed to a droplet. So we know we live in a society with this kind of organization and I can’t help but think, coming out of this crisis, we should think about what kind of society we really want to live in, and whether we want to put our fellow human beings in this kind of jeopardy and organize a society in this kind of way. Really, I mean an injury to one is an injury to all after all.

Let me ask you about this idea of bedside manner. At a time like this, you know, people are really having gut wrenching experiences, not being able to be with loved ones who are dying and who know that, you know, they might be flagging, and they have to go on to machinery and they might not wake up from it. How is Albany Med dealing with that particular circumstance?

So I would just amplify the sensitivity. There was a day last week where I think I think I had three episodes. Sort of bursting into tears myself with what was happening to the patients and the anguish on the other end of the line and having to do it by telephone or you know, iPad, video chat, just unbelievable anguish. Albany Med got ahold of a whole lot of iPads. I thought, I thought that was really something. Then that huge wave of patients came and everyone was running. And we, we were like, oh my gosh, we need help. So we texted medical students who we knew were looking for something to do because they’d been pulled out of class only the week before. And this unbelievable crop of volunteers came into the building saying we’ll do anything we can to help. Well, it’s a little bit awkward because in terms of direct involvement in patient care, that really wasn’t something that the medical school wanted, that’s why they were sent home. But maybe there was some organizing thing they could do. And so it turned out that the medical students were geniuses at contacting the patients’ family, setting up a video conference call that was even HIPAA compliant. And you know, the privacy compliant, setting up dialogue between the doctor that the patient’s family needed to talk to, or the nurse, but most importantly, the chance to see the patient through an iPad and to call their name, and to maybe have a dialogue. And this project has really been remarkable. We read about Wuhan encouraging this for patients in the hospitals, encouraging that the patients be allowed to keep their cell phones charged so that they could use video conferencing to talk to their loved ones. But in Albany Med, it’s turned out to be quite remarkable and I’m very proud of my students and all the students who have volunteered. The students have, because they’re doctors to be you know. They’re looking forward to, to really taking charge of their patients’ cases in the future. And they have that consciousness. They’ve wrung an enormous amount of meaning out of the human experience of, of caregivers, the caregiver patient relationship, the caregiver family relationship, the role of the nurse, and how to facilitate our communication as the attending physicians. I think I think Albany has pioneered something. And I also think those students will be trying to tell the world about it.

How has it affected you? You said you’ve gotten emotional on several different occasions. You’ve been a doctor for a long time. I’m sure you’ve seen a lot of very difficult situations in the hospital and in your work. How are you dealing with it?

I don’t know that it is anything new. I think the social context has become very, very interesting to me as I’ve practiced longer. The social determinants of health have become much, much more important to me. You know in WAMC’s, listening area we have we have some incredibly spiffy communities. We have Lake Placid. But we also have Moriah, this is in the Adirondacks. You know, we have Loudonville where Siena College is. But we also have Lansingburgh, north of the downtown of Troy. Albany, sad to say, sometimes seems to me a little bit like a segregation city where there’s the north end and the south end, there’s Arbor Hill in the south end, I should say. And there’s the west end. And if you think of where your patients are coming from, in terms of their socioeconomic status, their culture, the resources in their community, you gain a certain consciousness about, about what’s happening. And you know, there’s a great, old, proud industrial working class in our area. In other words, an elderly population that GE Schenectady, you know the steel mills that used to exist, in this area, the vigorous railroads that were much more robust. There’s also this enormous state workforce and many, many, many colleges. See, you think about all of that socially and socioeconomically coming at it from that point of view. What’s so grindingly obvious is that the people who have the least, and are the most essential to society are the most vulnerable when we’re in a situation with where essential workers, and that means our African American community, recent immigrants, are the most vulnerable because the social conditions in which they live are the social conditions that facilitate the spread of the virus. And that was made extremely obvious to us by getting this bolus of transfers from Queens, but it’s also true locally. So I think from my point of view that that social aspect has been particularly painful because it’s not the country I want to live in.

You were a big advocate a decade ago or so when there was a lot of discussion about the future of healthcare in the country. And the Democrats started working on the Affordable Care Act for a national system of some sort. Joe Biden, who’s going to be the Democratic nominee, has said that a single payer system, Medicare for all, it’s just too expensive to pull off. But during this particular crisis, a lot of aspects of what single payer might offer have been put in place, including waived fees for tests and things like that, that we might see in another country that had a different format. Do you think that this experience that we’re having right now might cause us to as a country to rethink some of those plans as we head toward the fall election?

There’s no question that coming out of this crisis, the United States will need a national health program with planning that guarantees health care. All the unemployment that’s coming, will all by itself, break the employer based private insurance system. I want to add a couple of things on a little bit odd observations. So, you know, we have a local, not for profit insurer that is very important to the community in terms of the number of patients that it covers, the Capital District Physicians Health Plan Program, CDPHP Capital District Physicians Health Plan, very, very keen on moving quickly to remote medical visits that are compensated, you know, video over the computer, medical care, waiving fees for mental health visits, very conscious of the needs of the community, and very nimble. And so I would think that any future administration of healthcare, maybe not through an insurance scheme, but certainly through regional leaders, conscious of the needs of the patients, should be able to redirect resources just like that, you know, so very, very responsible to the needs and also to the resources available. So I would think that there’s got to be some kind of local regional planning, that makes sense based upon the health needs of the actual community on some kind of smaller than national scale. That would be one component, that my consciousness has been a little bit raised by this because certainly the needs of Elmhurst Hospital are going to be different than the needs of say, St. Mary’s Hospital in Amsterdam. The other side, though, is that I’m not sure that a single payer, one insurer that pays all the bills, goes far enough, because if we’re physicians who have a consciousness of what our patients actually need, we know that our patients need all necessary care to be provided through planning ,period. And so to do that through a financial mechanism, does that really make sense? Maybe it makes sense better to do it through an administrative mechanism. Maybe instead of Medicare for all, we should have the Veterans Administration for all of them, Veterans Administration, greatly expanded, greatly empowered to provide all care and simply say that like the National Health Service in England, medical care will henceforth be free and available to all because it’s a pride of our democracy, that absolutely every person should get the best possible care when they need it. And we’re going to organize the whole society to do that. In the meantime, however, the least, the very least needs to happen is to begin to drop the Medicare enrollment age, you know, from say 65 to 55, to 45, to 35. Some kind of incremental expansion of Medicare. And then on the other side, Medicare has to be improved because Medicare doesn’t pay the dentist. It doesn’t pay the optometrist, there’s all kinds of things that Medicare doesn’t cover, and Medicare needs to be quite expanded. And finally, Medicaid, the program for the poor, Medicaid should absolutely not exist. There should not be a separate program for the poor. There should be one program for everybody. And so Medicare for all demand is the least it could happen. And I would even think this is kind of a thing that people won’t maybe agree with as a conjecture, but I could see, I could see Donald Trump embracing Medicare for all because the crisis gets bad enough.

No, no, no, you couldn’t. Really?

No, seriously, I think that when something’s got to give, when something has got to give, because the crisis has gotten bad enough, now we’re talking about, we’re heading for 30 million unemployed? Is that right?

Yeah.

In the last few weeks, how many are in the workforce? What percentage are we at? Didn’t I read that a majority of people in Los Angeles are unemployed, more than half of the workforce are unemployed? So we’re talking about an enormous collapse of jobs, an enormous collapse to production, and an enormous collapse of demand. So both supply and, right the production side, because no one can get to work and demand, because no one has any money. We’re talking about a major depression. And when a crisis like that is recognized by everyone in society, everyone top to bottom, there’s a major crisis and something’s got to give. At long last, it will be time to do something really meaningful and lasting for the working people of the United States of America. Now, maybe an expansion of Social Security administration would make sense. Let’s drop the retirement age to 50. Let’s scrap the cap, the payroll cap on contributions to Social Security. Let’s have a progressive Social Security contribution, you know, instead of 6%, we’ll put it up to 7% if you make 200,000, 8% 300,000, 9%, so on until Social Security has robust funding, because it’s a progressive tax on the wealthy contributors, and then the retirement age has dropped to 55. And everyone has a guaranteed retirement income, maybe something like that. But when something really has to give, I would think that the leaders of the United States of America, whoever they are, whatever party they’re from, they’re going to go with something that’s known. And the single payer proposal is a very well-known. It works, in many countries, and for 30 years, we’ve been campaigning for it. So it will work. That’s the funny thing about the single payer proposal is it will absolutely work. I know that. I know that the candidate Biden has all of the usual corporate talking points, but that just reflects his donor base, not what people need.

Dr. Andy Coates. This is not a political statement, but I admire your optimism. Thanks for coming back on and let’s keep the conversation going. Again.

Okay, I hope the interview is useful. I’m very grateful to be on the show, and thank you for WAMC.