- [Announcer] Thank you for joining us for Our Healthcare System is Sick, with Vin Gupta and Cassie Sauer, moderated by Will Stone.

Before we begin, thank you to our founding sponsor, the Kerry and Linda Killinger Foundation.

- Hello and welcome to the Crosscut Festival.

My name is Will Stone.

I'm a reporter and editor on the Science Desk at NPR News.

I live here in Seattle and I cover healthcare, which since February 2020 has meant pretty much non-stop coverage of COVID and all the ways it has effected the US healthcare system.

The patients who've caught the virus or had their care disrupted, the healthcare workers who've faced extraordinary challenging circumstances, and the hospitals that have been overwhelmed and endured wave after wave of COVID.

And of course, none of this has happened in a vacuum.

In so many ways the pandemic has really exacerbated other systemic problems in healthcare.

So today we are going to dive into what those are, the impact of COVID and what might be done to address these chronic challenges.

And I'm excited to put these questions to two healthcare leaders.

First we have Cassie Sauer.

She's the CEO of the Washington Hospital Association, which advocates for all hospitals and health systems in Washington state.

She previously worked for the Children's Alliance, where she worked to advance public policy, particularly in healthcare, food, and nutrition for children and families.

And joining Cassie is Dr. Vin Gupta.

He's a pulmonologist who currently works as the Chief Medical Officer for Amazon.

He's worked with organizations including US Centers for Disease Control, the Institute for Health Metrics and Evaluation, the Harvard Global Health Institute, the World Health Organization, and the Pentagon Center for Global Health Engagement.

He appears as a policy analyst on CNN, NBC, and the New York Times.

Dr. Gupta, Cassie, welcome and thank you for joining me today.

- Thank you.

- Thanks for having me.

- So, there have been so many challenges for hospitals and healthcare workers over the course of the pandemic.

Before we get into all of those, I'd like to start with asking you about the moment we are in right now.

Clearly, the virus is still out there.

There's always the possibility of new variants.

Our vaccination coverage could be better in the US.

But, it does seem like we are in a new phase as we make our way further into 2022 living with COVID.

And so, starting with you, Dr. Gupta, Vin, how does this moment feel to you?

How would you describe it?

- Will, thank you for having me.

Cassie, it's great to be here with you.

It's a moment of hope, but cautious hope, cautious optimism right now, Will.

I'd say for everybody that's tunin' in, between now and around Halloween of 2022, we should expect some degree of normalcy when it comes to the stress that COVID's gonna place in our ICUs and our hospital systems across Washington state and across the country.

Cassie can speak to that with even more greater detail than I can.

I work at Virginia Mason part-time.

I'm a Air Force reservist so I I've deployed to other zip codes across the country over the last two and a half years.

I've seen what we've contended with elsewhere and really felt privileged that I get to work with the amazing health systems here in Seattle.

And so, I suspect that this is going to be a time of relative normalcy.

We're not gonna zero out on hospitalizations.

People will continue to die from this virus and it's gonna continue to change.

We should expect that, because that's what happens with contagious respiratory viruses.

I say this as a pulmonologist, this is not unusual.

We should expect that we're gonna hear about a seta variant, a theta variant, maybe a sub-variant of Omicron that's not BA2, something else that's arisen either here or elsewhere.

This is the natural evolution of contagious respiratory viruses.

It shouldn't alarm us.

And really we're reckoning, Will, right now with the purpose of vaccination.

Omicron forced us that day after Thanksgiving, you probably remember that.

I remember really vividly, day after Thanksgiving, reckoning with why do we get vaccinated for things like influenza, now in this case, COVID-19?

The purpose here is not to prevent a positive test.

It's not to prevent mild symptoms.

It's to keep you away from an ICU from a hospital.

And we had to reckon with that pretty quickly right after Thanksgiving until literally as we're having this conversation.

People are still reckoning with that reality who should and should not get a booster.

This will be the nature of the conversation moving forward, understanding why we do what we do.

It's not to prevent cases.

We don't have that tool in the toolkit.

It's to keep people out of the hospital.

Since we've aligned on that now I think it's clear to me what success is gonna look like.

Maintaining low stress in hospitals coming in the winter of 2022, and that to me, is gonna be the near term challenge.

- Cassie, you have this wide view of the healthcare system in Washington, and I wonder what does it feel like for the hospitals you represent?

Does it feel like COVID is still very much with you and we're still in a pandemic, or does it feel different?

- It does feel like we're still in a pandemic and I think there's a lot of worry about what comes next.

We've had, I was looking back on, thinking we were gonna have the freedom summer in July, that was announced July 4th of 2021.

We were all giving thanks at Thanksgiving.

Vin mentioned the day after Thanksgiving now we could all be together, we were done.

And then, it came roaring back.

So, I think there's just a lot of trepidation about what might be coming next.

And you add on to that the stress of people who's had very delayed care throughout the pandemic, either by their own choice because they were nervous about going to a healthcare facility, or because of the orders to stop doing non-urgent procedures.

And there's a lot of people whose health conditions have worsened, not COVID related, that we're grappling with as well.

So, that backlog in Washington hospitals is really significant.

I also would add to Vin's comments about the purpose of vaccination is to keep you outta the ICU, absolutely, even more so, keep you outta the morgue.

I mean, that's the thing that I find remarkable is there's still hundreds of people dying every day in America from this disease.

And thinking, if you're one, like America, we sort of have this attitude now of like, it's over, you don't have to wear masks anywhere.

You can fly on a plane without masks.

If you're one of the people who is dying or you've just lost your person to COVID, it must feel just like a, just such a weird moment in time that everyone seems is sorta moving on.

And meanwhile, you are just moving into incredible grief.

- Cassie, I'd like to stay with you and I guess, because this panel is about problems with our healthcare, although we're gonna get to solutions as well.

I'd like to talk to you a bit about you know, could you pick one, two, of the biggest vulnerabilities in our model healthcare, how we've been delivering it, that you feel COVID really exposed or exacerbated, you know, from your perspective as someone who represents you know, hospitals?

- Yeah, I think, I think one is health equity and the inequitable access to information, to treatment, different levels of trust with the healthcare system and in different levels of underlying healthcare conditions that exacerbate a disease like COVID.

If you look at the death rates by race in this country, it's shameful.

It's you know, something we really need to address, and I think that's very much come to the forefront.

Another vulnerability for us, from the hospital side, is staffing.

You know, we, we were overwhelmed by COVID and we have a lot of staff who are very traumatized.

The normal, Vin, please jump in on this, too, the normal ICU death rate in many of our hospitals is about five to eight, seven, eight percent.

That's about that number of patients die.

In the peaks of COVID it was more like 35 or 40%.

So if you're a staff person who works in an ICU, you see death for sure, but you don't see it at that rate.

And you also don't see death like this, which is many younger people, many people with young families who can't be with their people.

You know, they're in by themselves, upside down on a ventilator and no one can speak to them and no one can say goodbye.

And so, that adds to the trauma because they absorb so much family trauma.

And so, we are, that's a big vulnerability for us right now is just how do we help our staff recover and be prepared to care for people in the way that they need to.

- And Vin, can you, I mean, I'm sure you have some other things to add to this as a clinician, things you were probably aware of well before COVID, but you you know, COVID really kind of shone a light on it.

- You know, Will, to build on what Cassie just mentioned, I, sometimes we came face-to-face pre-pandemic to this notion of staffing, but not really to this extent.

I mean, I was just in the ICU all last week and the rate lending staff was not physicians.

It was not respiratory therapists.

It was not dialysis bags, literally the bags that you need to run a patient on with dialysis.

We were lacking that about six months ago across the country, it's nurses to staff ICU beds, at least in the hospital systems that I've worked in, both here and elsewhere.

We don't have enough.

And in part it's because some of the therapies that we wanna deploy when the ventilator isn't enough, like ECMO, literally sucking the blood out of the patient's body, sending it to an oxygenator, sending it right back in, cardiopulmonary bypass some folks might be familiar with.

That's labor intensive.

You need advanced critical care nursing skills to support that.

So when we're talking about addressing that mortality rate in the ICU that Cassie talked about, that really high mortality rate, in the absence of miracle therapeutics that we still lack in the ICU, really it's TLC and team short time.

And so, the things you need there to make that successful are adequate staff and we don't have that.

What I was alarmed by is six months prior to when I was deployed to southern Ohio towards the end of September in our Air Force Reservist capacity and we sent a team.

It was myself, a respiratory nurse, a respiratory therapist, and a nurse, was a critical care transport team from Lewis-McChord.

We went to southern Ohio.

We were there shippin' patients from Chattanooga all the way up to the Cleveland Clinic that were part of this advanced therapeutic in the ICU, this ECMO procedure.

And we were in the C17 and C130s, Will, that JBLM, Lewis-McChord utilized and sent over for the Kabul evacuations six months prior.

So, in the summer of 2021, the same infrastructure that was being utilized to move Afghanis and Americans and other assets from Kabul elsewhere to safety, six, and literally not even six months, three months later, they were being utilized to move Americans to advanced levels of care for COVID treatment.

That's not sustainable.

And that was our short term fix in many cases for this healthcare workforce crisis.

Let's deploy the military, our military medical assets.

We're gonna lose 30% of doctors, 40% of nurses by end of year, probably, these are numbers that were predicted pre-pandemic.

That's probably much worse in terms of what the forecast is in terms of attrition from the healthcare workforce.

Deploying the military is not gonna be a permanent fix.

When this happens inevitably again, we need to think about ways to train more nurses, more support staFF, more physicians, retain them.

I'll say that the respiratory therapist that I deployed with got hazard pay in uniform.

As a civilian working in Tucson, no hazard pay.

It didn't make sense.

Basic things I think we can fix so that we can help solve this problem.

Technology also is gonna be a solution as well.

But, that to me, is the crisis of our time looking past COVID.

- Well I mean, looking a bit at some of the real extreme moments over the last two years, and I know as like, a member of the media, that's when we're calling the doctors, that's when we're calling Cassie.

It's when things are really bad, because we should be paying attention then.

But, I wanna kind of ask you a bit about what happens after that, you know, after the surge, after the adrenaline of having a big wave hit the hospital and maybe starting with you, Cassie, what do you see after, after we stop doing the stories?

But, clearly there's a huge mark on the patients, on the healthcare system.

- Yeah, and I think there's both good and bad.

I mean, there's certainly the stress which was just described with the staff.

In Washington state we have a ton to be proud of.

I don't know if folks have looked at our death rate per capita, but we're like the 5th lowest in the country states of death rate per capita, and we were the state that was surprised by COVID.

Everyone else got to learn from us.

And I know we were, I'm sure you were as well, Vin, telling everyone who would listen, like here's how you prepare, here's what you need to do.

But, the public's support for being cautious here was definitely better than in many places.

The hospitals' collaboration here was unprecedented in other, versus other parts of the country.

We actually had written agreements in all of our hospitals that no individual hospital would ever go under crisis standards of care alone, that we would move patients, we would move PPE, vaccines, remdesivir, ventilators, staff, you know, whatever was needed, mostly patients was what moved the most, to level load across the state.

You know there were, we had huge surges in like Yakima and Wenatchee and they could not, those communities could not have handled those surges.

There is no way.

So they were sending patients all over the state and hospitals were willing to take them.

And so, I think that there's a lot that we learned out of how do we work better together, how do we make sure that we're prepared for a future surge?

So, there's I think some of that, those good things are also carried forward in addition to the trauma.

- Hmmm, what did it do to your hospital after you had gone through a big wave?

I mean, what did you see in terms of your staff or the patients, you know?

- I think the fatigue was significant among everyone.

The patients were, either the patients who had COVID were off, many of them were still struggling with, if you were sick enough to be hospitalized in many cases, people are not well, they're still not well.

They're home, but they're not well.

And so, that's really a big deal for them.

But, we also have, as I mentioned before, a huge backlog of folks who had care delayed.

And some of this you know, this non-urgent procedures prohibition, which we had major concerns with, people hear non-urgent procedures and they think face lift, and that's not what was delayed.

It was things like heart valve replacements and joint replacements and some things that really don't have a health impact but have huge psychological impact.

One of the stories that we heard several times was folks who'd had abdominal cancer and who had a colostomy as part of, complete their cancer treatment, but part of their cancer treatment involved having a colostomy.

They were scheduled for reversal of that colostomy and that colostomy reversal was delayed by three, four, five, six months.

Now, just imagine if you had had cancer, had been through the whole cancer treatment, cancer surgery, had a colostomy, which is terrible, think you're gonna get it reversed, and you're told you have to wait three months, four months, or even we don't know when we can do this.

Like, the psychological impact of that is really tremendous.

So, I think that non-urgent notion and how that's effected people and people have gotten sicker.

People who needed a joint replacement, their mobility has declined tremendously and that comes with other health problems.

So, there's a lot to recover from for patients for sure.

- Well Vin, what, in terms of patients and the disruptions, massive disruptions, even not even directly the people who were effected house wise for COVID, what have you seen and heard about from your colleagues?

- You know, it's interesting.

In any given day I feel privileged.

I could be caring for a patient at the bedside, and then see what interesting solutions are being developed in the virtual telemedicine space, for example, meeting patients now where they wanna be met, which is I don't wanna come and drive into Seattle and pay parking and figure out a way to walk into the hospital, especially if it's on a hill.

I want care at home.

And many of the integrate healthcare systems across the country, many of the healthcare systems here in county across Washington state are developing virtual medical homes where care is more convenient and people can get services on demand.

And now we're seeing it play out in real time, Will, this sort of concept of test and treat, which I'm really and I know many of my fellow clinicians, Cassie, and other healthcare leaders are really passionate about, this concept of how can you intervene early in a convenient way to somebody's acute, infectious illness like COVID-19, and then get them treatment within the prescribed window of time?

I'll just, I'll speak from my own experience, that I think we sometimes struggle with early test to treat, whether it's for flu, COVID-19, other sepsis like conditions, infectious ideologies that can cause you to end up in the hospital, urinary tract infections.

STIs, other pneumonias that are not COVID-19, we sometimes struggle to get a timely test and then get timely treatment.

And that's, and so, I think if there's a silver lining here, it's that people are now willing to do, to not necessarily say, no, I gotta go and drive in to see my doc or my medical provider in clinic.

I have to have that face-to-face conversation.

They're now willing to do things differently.

I think the pandemic accelerated behavior change, a willingness to try new things like staying at home, doing a phone visit or a telemedicine visit through an app and now potentially, we can get them treatment at home as well, 'cause you know what?

They're testing themselves anyway for COVID-19, probably with a rapid test at home, not with a lab based test that goes to a hospital.

So, we're moving meaningful clinical services to the home.

I think this will be ultimately a good thing for Cassie and the hospital systems that she oversees across the state because the biggest driver of avoidable healthcare costs across the country is for avoiding sepsis like illnesses, hospitalizations from sepsis like illnesses, acute, infectious diseases causing somebody to end up in a hospital.

Early intervention, early treatment, big silver lining in this pandemic, in my opinion.

- Well, let me just follow up on that, because I mean, is the test to treat really working the way it needs to and is this just gonna be a passing thing with COVID while there's money and momentum?

It's not gonna get carried over to all these other challenges we have.

I mean, what are your thoughts on that?

- Yeah, is it optimal now?

No.

In part, because there's a lotta kinks that need to be worked out.

One, we don't have enough supply of Taxol in this case, that oral anti-viral that I'm sure many people have heard about developed by Pfizer.

There's another one developed by Merck, both effective to varying degrees at keeping folks outta the hospital, but are high risk they end up with a positive diagnosis.

Once we get more supplies, supply is improving, access will be easier.

Is it gonna be perfect?

No, because they're still hearing, Kaiser Health News just reported some people have to drive 100 miles from a rural county to an urban, ex urban county to actually get access.

That's unacceptable, which is why we're virtualizing it.

We can't provide at at home test and not then provide the other part, the care continuum, which is, which is care connecting with a provider, and then potentially treatment.

If we're gonna do one part of that care continuum at home, in my opinion, we need to do all of it.

We have to provide that entire journey also at home conveniently.

And to your point, is this a passing thing 'cause there's attention being paid here and there's money?

This is where payers gotta get involved.

Big payers, Medicare and Medicaid, 3rd party payers like Medicare Advantage Programs, you name it, private insurers, employers, are interested in these types of innovations.

How do we keep people at home that would otherwise end up in the hospital?

Because we're monitoring them remotely with a new device, because we have virtual test to treat.

There are different new innovations here that can keep people at home and that's, once you start getting the attention of payers, that's when innovation gets embraced.

That's when, that's when people actually utilize these services.

And so, this to me, is a start of a trend, not just a fad.

- And there actually is a hospital at home program that was allowed during COVID that is based on waivers that are going to the public health emergency.

That's something that's interesting.

A lotta the waive things, things that were waived only can be waived as part of the emergency and if the emergency has ended the waivers end.

So, we are active in advocacy to keep the hospital at home program going and to expand it.

I actually had my dad in it and it was amazing.

He had a cough, I called, they sent an x-ray team out.

They were there within an hour.

They x-rayed his chest to see if he had pneumonia.

Like, it was amazing.

- And just so people understand, why is this good for you, the hospital?

Why is this good for your father beyond just not having the hassle of having to go to the hospital?

- Because he could stay at home.

He has Parkinson's Disease and he gets confused.

And so, that having to go to a hospital would be, is challenging for him.

So that's, for many patients, that's a good thing to be able to be at home.

But, for the hospitals, we're full.

Hospitals are full, full, full.

So, being able to treat people, we're turning people away.

So being able to find other places to treat people and have them be able to be at home is really great.

- So, just a quick reminder to everyone who's watching, that we're going to be asking some of your questions pretty soon, so be sure to enter them into the chat section and I'll put them to our two guests here.

So, I do wanna kinda get back a little bit to the healthcare workforce and go a little deeper there, because I mean, it's such a huge issue with just hearing all kinds of healthcare workers dropping out of the workforce at unprecedented rates.

And you know, the news stories kind of feel hopeless sometimes, like everyone's burned out and they, maybe they love the profession, but they just feel like there isn't a place for them anymore.

So, Vin, I mean, starting with you, you mentioned some hazard pay, but maybe could you elaborate?

If you, I mean, if you got to make a wish list of two or three things that would, you could offer to nurses or to doctors or you know, any kinds of healthcare workers to keep them in the workforce, I mean, what would you pick?

- Well, we just need more.

We artificially, I mean, for everybody watching, we artificially limit, let me take my ilk, my fellow MDs and other medical providers, the number of MDs, physicians that can be trained in every given year is artificially limited by, by Congress.

There's a limitation on how many can actually get into training every year.

So, demand is always greater than supply of clinical training seats in any given year.

And maybe that made sense for the last 20, 30, 40 years.

It doesn't make sense anymore.

We need to revisit some of the policies and the assumptions that were put into place well before the pandemic, because we are lacking a diverse, well trained, new generation of physicians that's gonna come and backfill the many more that are leaving.

So that's number one.

We need a policy shift at the highest level so we can fund more seats for more aspiring clinicians.

Same thing with nursing school, same thing across the board for other healthcare workers.

We do not have enough seats to train future nurses, more of them, respiratory therapists, you name it.

That's why, we have a limited, our existing healthcare workforce crisis is in part, self created based on policies that have existed for many decades.

That needs to be revisited.

That's number one.

Two, I would just say, let's take a playbook out of our friends across the Atlantic.

More of these programs that allow individuals who know, you know what?

I know I wanna be a nurse.

I know I wanna be a doc.

I know I want a PA. And to make, be able to make more of that shift, more of that paradigm jump directly from secondary school, high school, to essentially healthcare vocational school, whether it's medical school or you name it.

We need more of those direct paths to cut down on the time people are actually accruing debt and not making a paycheck.

One of the big limitations here, I mean, plus medical school and training, I didn't actually get into the workforce and make a durable paycheck to help pay off debt.

It's one of the reasons I joined the military as a reservist, until I was in my mid-30s.

That's problematic.

That's not scalable.

And that was to become an ICU physician, which we need more of.

So that is not sustainable.

We need to rethink, what are the different opportunities we can get people in to these different professions and take a playbook from other paradigms that work.

And then lastly, I'll just say, we talked about paxlovid and this access to therapeutics, you know, the lobby and interest groups that impact policy, prescribing policies, what say pharmacists can and cannot do, what physicians can and cannot do, what they can get reimbursed for.

The physician lobby's a powerful lobby and it makes no sense to me.

Taking some of the burden off the doc, for example, when it comes to getting access to paxlovid.

We need, across the country, more pharmacists, for example, to be able to do more things.

Rule in or rule out if somebody is eligible for paxlovid on the spot, they can prescribe it.

Other medications that should be near OTC, that will be helpful.

That'll also unburden the rest of the healthcare system for having to deal with some of those really crisis moments, maybe keep them out of the hospital as well.

So we need a deep breathing care of some fundamental policies so that we can really have a sustainable future.

- Well Cassie, I mean, obviously this is, you brought this up right away.

It's huge importance to the hospitals and we hear about nurses leaving hospitals, right, these travel, these lucrative travel nursing contracts.

Anywhere you look around in your state, in the country, you say this institution, this place is doing it right, they're giving nurses and doctors X,Y,Z and it's keeping them staffed?

- I think a lot of what we, I totally agree with everything Vin said.

I wanna say that to begin with.

Thinking about what are the supports that we can provide to people so that they can work or they can go to school.

A couple of health systems in Washington state that decided that they would pay childcare for their staff, because childcare, I mean, childcare was horrible for the healthcare workforce, which is large, then nursing staff are many women who have younger kids who are, even if they're partnered, they often the ones that are most responsible for the kid care.

And with schools closed and daycares closed and the unpredictability of that, that has been really challenging.

So some health systems said, we will pay your childcare if you'll come to work.

And they started with saying we'll pay for your childcare at a licensed childcare center and a lotta those were closed.

And then they started saying, okay, we're gonna pay for your childcare, we'll pay for your babysitter.

We'll pay for your mother to take care of your kids so you can come to work.

So that kind of support.

That really brought people back.

It was actually really positive intervention.

More academic support beyond, I totally agree with what Vin said about debt.

I would like for people that are going into healthcare, especially if they're willing, if they're working at a hospital, you know, it's kind of an institution that's providing broad public service, a hospital, a community clinic, to not have to be paying tuition at all and to potentially be getting stipends as well for while they're in school so they can pay their rent and they can pay their childcare and we've got a lot of folks who want to work in healthcare.

Actually our state turns away thousands of people who wanna be in nursing school every year.

We are educating fewer nurses right now than we did a decade ago in Washington state.

It's remarkable.

So but, to really reinvigorate that education system is critically important.

- Well, I wanna think of it about kind of these different spheres of healthcare.

You know, we have the hospitals.

We have the healthcare system.

Then we have public health and it was so kind of on display throughout the pandemic how these two things need to be, how interdependent they are and yet, how they often aren't functioning well together in our society and we saw this in all kinds of ways, right, from interventions like masking and vaccines, you know or vaccines.

And I just wonder looking ahead, and start with you, Vin, what do you think the way forward is here?

Because it doesn't you know I don't think anyone's leaving the pandemic feeling great about how, well at least there's a huge polarization, right, on a lotta these things, and I wonder how you see kind of we can bring these two spheres together better.

- I think you're right.

And to me, you know, this concept, this division of well, there's the healthcare system, then there's the public health system.

A lotta people, I mean, if you poll, just do a public poll, I wonder how many would actually know that there's a true difference, appreciate that there's a difference between getting healthcare in a hospital setting versus you know, what does public health do that looks after population of the health, the health of a community, for example, sort of policies that keep a community safe might, might seem out of touch for what an individual feels is or is not appropriate.

Let's look at all the debate on masking on airplanes, as an example.

You know, one is, those of us who think that that policy makes sense still to this day are thinking about that through the lens of public health, not necessarily through somebody's individual considerations and whether or not they may need individual healthcare in a healthcare setting.

It all comes down, Will, more than anything, I mean, of all the lessons, all the take homes that exist, you know we can, Cassie and I can spend the next several hours talking to you about.

More than anything the interdependence of our public health system and our healthcare system, why it matters.

To everybody watching right now at home, it comes down to being better communicators.

At least, I'll say for medical schools.

We don't have any, there is no crisis communication class.

How do you communicate in a healthcare crisis so that people understand why we're doing what we're doing in the simplest, most effective means possible.

That is a learned skill over time, that individuals, leaders in industry, in business, politics, and the military, I mean, they could double crisis communicators so that people understand.

They may disagree with the prevailing policy, but largely speaking, in many of these industries they at least understand why something is being done through simple, effective crisis communication.

We did not have that bench of crisis communicators coming in to this pandemic in March of 2020 and that's why you saw that there was confusion on why are we pursuing a set of policies for public's health when it may not make sense for an individual and their own sorta healthcare calculus.

That has to change.

We need to invest in crisis communication.

We need to invest in better ways to think about how we use social media.

You know, most people, I showed this picture, you know, Cassie, you and I chatted about this.

But, it's a picture of lungs with COVID pneumonia, impacted by COVID pneumonia and then clear lungs from that patient that's vaccinated as a simple way to explain why you get vaccinated against this virus.

And the engagement was something simple like that, a simple message, sort of akin to how we message on why you should not smoke, for example.

Just vivid images got millions of engagement hits on social media versus, you know, other messaging, maybe in peer reviewed academic journals that people just are not, are resistant to engage with, because it's not that engaging.

We need to understand how to use the social media space effectively.

We need to develop a crisis communicator so that we can clearly articulate the difference and the interdependencies between public health and healthcare delivery.

- Well, Cassie, and what we're gonna go to our audience questions in a moment, but I wanna get your thought here, because obviously, you know, what happened in public health and the community help dictate whether your hospital is gonna be overwhelmed or not.

- Yeah.

So I will say, I have huge respect and admiration for public health leaders in Washington state.

We are so lucky.

John Weisman, he was our former Secretary of Health at the beginning of the pandemic is extraordinary.

Dr. Kathy Lofy, who was our state Health Officer, also just amazing.

Dr. Shah's been wonderful to work with.

We've got Dr. Duchin in King County.

We've got really visionary public health leaders.

So I didn't actually experience a division between the healthcare system and public health.

It was more what Vin was just describing about when did the public believe and it became political, you know.

Like, if you're wearing a mask are you making some statement about who you are as opposed to what the science says?

And I felt, what I continue to feel frustrated by in this situation, I'm low risk and fully vaccinated and boosted and I'm still really careful.

You know, I wear my mask everywhere I go still.

And it's not, it's sorta for me I definitely don't wanna get COVID, I haven't had it.

But, I really don't want other people in my community who are elderly or have Parkinson's or cancer or you know, whatever, to get it because their chances of survival are so much worse than mine.

And so, that sense of I'm doing this as a gesture of caring and concern for my community as opposed to like, you can't muzzle me, you can't make me wear a mask, that kind of individual like, it's only about me.

And that feels like a real rupture in America is that, are we, are we a community in this together with caring and concern for those that are most vulnerable among us?

Or is it just like, this is about my convenience and my needs?

- Well that's actually a perfect segway into this the first audience question we have and this is it.

Relative normalcy doesn't really seem to apply to the millions of people who are immune compromised.

How can we reconcile the need for getting to some sort of normalcy for a number of folks, but also taking into account the safety of immune system compromised people, other high risk people for COVID?

Vin, you wanna start with that?

I think we're talking about the moment we're in right now, right, of this relative normalcy.

- Yeah, absolutely.

I empathize with that question because I've had a lot of people within actually given the times we're in across the country, but especially from King County, reach out and say, can you help me get one of these therapeutics, like Evusheld, this monoclonal antibody that people on chemotherapy, for example, can take and it can heighten their protection to avoid getting COVID, so it can help prevent an infection and end up getting sick if you don't man the normal response to vaccines.

And what those experiences, others across the country, their experiences with getting these therapeutics has given me this perspective.

It's that we can't, we should not be removing mitigation measures like masking on planes, masking in schools, as an example, I think the two in some ways are one and the same, using closed spaces where some folks are vulnerable, they are yet to be vaccinated like the case (mumbling).

Until, or they might be coming home, these kiddos that are even vaccinated might be coming home to a multi generational household where there's maybe somebody who's immuno compromised.

We shouldn't be getting rid of these broad public health measures until everybody has durable access who needs it to an Evusheld or to Paxlovid or to you name it, therapeutic, these tools in our toolkit that we like to talk so much about, they're still really darn hard to access for a lotta people who need it like the immuno compromised.

So to me, the balance is never gonna be perfect.

You're never gonna make everybody happy.

Some are gonna feel like it's too soon.

Others gonna say you know, what have you been waiting for?

And yet, the right balance in my mind is if we have, we can start to really release some of these measures, obviously, the cat's already out of the bag, but in the ideal setting we start to let go of some of these measures like masking in planes when somebody who wants or needs one of these therapeutics can easily access it.

And I'll just lastly say, perhaps as we enter the fall/winter period, if you're high risk and you're watching this, you're wondering well gosh, what do I do?

Come up with a care plan.

For my patients that are high risk I'd love to do a standing order for Paxlovid, as an example.

If they test positive, boom, they can go to the pharmacy and they can fill a prescription like steroids for an asthmatic.

That's the type of paradigm here.

- Cassie, do you have anything to add to that?

- Well, I think we have this vision of normalcy being we're back in the beginning of 2020 or the end of 2019, and I you know, I don't think wearing a mask is that big of a deal.

And I, that's something that I was sorta startled by, that everyone that that was just so proven to be such an effective intervention, feel so objectionable.

You know, like, as Vin said, why would we not keep wearing masks on planes to make sure that those that are most vulnerable around us are kept safe?

It's not, it's not a burden.

The burden on me to wear a mask on a plane is minute compared to the burden of someone on the plane who's got cancer getting COVID.

I guess what I'm saying is, I wanna modify our definition of normal.

You know, to be like normal with community care.

- So, here's another question I'll open up to both of you.

Are there studies that show a correlation between the prevalence of underlying health conditions such as diabetes, in people who work in low pay jobs if an employee can only afford to enroll in a company sponsored HMO instead of the PPO with higher premiums, does this effect levels of accessibility, hide inequalities, especially in the black and brown communities?

I'm not sure, is this something, can either of you take this?

- I got a little bit lost in the question.

- Yeah, yeah, well I think, I think the gist here is that you know.

- Does worse insurance mean you've got higher risk?

- Yeah, yeah, I mean, are people being you know, suffering you know, because of their insurance status on some level?

- I think that is true in many cases about various healthcare conditions.

However, I think that there were so many extraordinary measures put in place for COVID that if you got COVID the access to treatment in Washington state at least, was quite good.

But, I think that whether or not you got COVID to start with and what your underlying, the underlying conditions that you brought into the equation were very different.

Does that make sense?

And then.

- Yeah, no I was just gonna, I completely agree that even if there was, if there was concerns about healthcare insurance quality or kinda nature of the plan that you held before you got COVID, if you did end up getting it that once if you needed care because of the measures that were put in place, it was all one and the same.

You were still gonna get excellent care, it was gonna be robustly covered.

I will say that since it's we just got out of Earth Month, and because I think there was some mention, Will, in that question about where somebody may be residing, perhaps in a urban setting.

Just food for thought.

One of the, again, one of the maybe silver lining scenario, this may not feel like a silver lining, is there's been more of this focus on synergistic risks.

I live, I might have a patient who lives in an inner urban setting close to say a subway station or other public transit.

They're inhaling, by definition, poor quality air.

Turns out that that was an independent risk factor for having a more severe outcome from COVID-19 if you were exposed and infected.

And so, this combination of like the chronic risk factors all around me and the ambien environment, those that I can't even see, like air pollution, fundamentally change your risk to something like a infectious disease pandemic.

And that is, that's another one I wish we can really think about environmental health, climate change, however you wanna talk about it.

But, all these risks that we live with are synergistic.

They're not just isolated risks that we experience one at a time.

- Well, we're just coming up at the end, but I do wanna maybe get 30 second final thoughts from you, Vin, first on mental health.

We haven't really mentioned it, but it's come to the forefront in the conversation throughout the pandemic.

Would you say that the pandemic has shone a light on the importance of mental wellness?

Has it improved or worsened since the pandemic began in your opinion?

- I think it's worsened.

And especially you know, multiple studies have been done, lot of late critiques have been had on the impact it's had on younger people, adolescence especially.

And to me, that's where it's really important for us.

You know, we've been talking about what does relative normalcy look like?

Ultimately, as we think about approaches if there is another surge down the road, how do we handle this in a way where we're thinking also about the mental health impacts of younger people as we're trying to say protect those that are higher risk.

That is something that I've heard a lot about, a lotta critiques about well, you know, in protecting one group of individuals you're posing untold harm to a different part of society.

If we're saying, if we're advocating say on school closures down the road if we need to.

How do we balance that?

That's really difficult.

And yes, I do think the pandemic has shone a light on the need to balance everything and I'm sure, I've talked to Secretary Shah and others, you know, I know that they lived this and they make really hard decisions.

And to Cassie's point, we have the best healthcare leaders in the country in my opinion, and they have a really difficult job.

- Cassie, final thoughts.

- Yeah, I also think it's worse.

I mean, it's just the collective stress and the collective trauma over the last two years and the uncertainty about what comes next.

You know, we are people who, humans are people who like to know.

We like to know what's gonna happen.

We like to be able to plan and work towards a plan and it's very hard to know what the plan is.

I've got three kids, three school age kids and they're doing okay, but it's really challenging.

You know, that development.

I think the developmental milestones are wild.

Like I have a 16 year old who said, I think I like girls about two years ago and I said, any girl in particular?

And he said, how would I know?

I don't see any girls.

I don't think I'm gonna see any girls.

I don't know when I'm gonna see a girl.

It's like, that just, that's when kids sorta start dating a little bit.

None of his friends have done that because they're all wearing masks and keeping separate.

It's like, how do we get, how do you kinda make up for that time?

And we already have an epidemic of loneliness in this country and if people are isolated, you know, it's just like all those pressures.

I think we're gonna see how they, how they effect us I think for probably a decade.

- Yeah, well, we've run out of time.

I wish we could keep going.

I know both of you could keep going a lot longer than this, but just wanna thank you both for joining us today, for sharing your thoughts.

And there's a lot of work to do and a lot to think about going forward.

- Thank you for having us.

- Thanks guys.

- Wanna thank you to everyone for watching us at home, and I hope you'll check out some of the other sessions happening at the festival.

I suggest check out the conversation titled, Chasing COVID.

This is with Trevor Bedford, an infectious disease specialist with Fred Hutch who uncovered the early evidence of widespread regional COVID-19 transmission in early 2020 in Washington.

And went on to become a kind of bonafide Twitter celebrity explaining the evolution of the disease throughout the pandemic.

You can find out about that session and all the others at crosscut.com/festival.