New Approaches to Covid-19: Rapid Testing, Herd Immunity, and the Role of Narrative

good afternoon welcome back to ucsf medical grand rounds i'm bob wachter chair of the ucsf department of medicine welcome as usual to our live audience in the department throughout ucsf and to our partner sites throughout the ucsf health network we'll post this video tonight at about 7 30 p.m on youtube and i'll tweet out the address uh our previous grand rounds in this series have now been viewed nearly 800 000 times before we get started a quick program note we've been doing these grand rounds weekly since uh since mid-march we're going to take a little break next thursday at this time there'll be a presentation by the ucsf campus on the future plans for the parnassus campus including the new hospital the new research building so that will substitute for this for our live audience then we'll take a couple of weeks off for uh grand rounds for our entire team and we will come back after labor day on september 10th for another covet grant rounds uh starting at that point we'll alternate every other week doing a coveted presentation versus a more traditional medical presentation uh unless things heat up and coven in which case we will let's take over some more sessions on to today's session a few ground rules as usual are here you'll be on mute if you have questions type them into the q a box i will screen them and try to get to uh some of them we're now about six months into the u.s experience with the pandemic and while cases are down a bit overall we're still seeing extraordinarily high rates of cases and of deaths uh notwithstanding the russian sputnik vaccine it's likely that we're still a year away from a widely available game-changing therapeutic or preventative approach we're now over the early panic stage that we all experienced in march and april what i think of as the complacency stage of may and hopefully we're moving toward the latter parts of the summer surge phase that we've had for the last two or three months well much of our approach has involved pandemic 101 searches for vaccines medicines and non-pharmacologic traditional non-pharmacologic strategies we're starting to see some out of the box thinking new paradigms new approaches new approach new ways of attacking uh covet and today uh we chosen to highlight three areas in which these new approaches are being proposed and implemented i think the presentations will be eye-opening maybe a little controversial and will demonstrate the importance of attacking this pandemic in creative ways the presentations will go till about 120 the first one will be from michael minna michael is assistant professor of epidemiology at the harvard chan school of public health and a core member of harvard center for communicable disease dynamics i will be on an issue that was first first i became aware of uh when chas langley presented here about three weeks ago the potential value of changing our testing strategy moving from a highly sensitive pcr-based testing strategy to one whose backbone is faster cheaper more scalable but less sensitive viral tests uh michael will speak for the first 30 minutes or so and although he looks live in this picture we actually uh taped our presentation with him a couple of days ago he couldn't be available right now so don't put in q a's for his session uh it's already it's already uh uh on video uh we'll then shift to two live presentations the next will be a presentation by trevor bedford who's associate professor of epidemiology and genome sciences at the university of washington and at the fred hutchinson cancer center hi trevor trevor works at the interface of evolution epidemiology and immunology and he studies computational and statistical methods to understand viral dynamics trevor has 260 000 twitter followers and i am one of them quite avid i proposed a fascinating hypothesis on twitter a week or so ago related to the dynamics of herd immunity as it relates to covit so i've asked him to discuss it here and we'll do that from about 12 30 to 1. finally while much of our approach to covet hinges on the sciences of virology immunology epidemiology clinical trials and the like at its core most of our response depends on attitudes and behaviors how do people assess their own risk how do they assess the risk of those that they care about are people empathetic about others who have risk or who are sick do people understand what it feels like to care for patients with covid as a clinician or as a family member and given the evidence of disparities in kovid and the coupling of this pandemic with the vivid examples of racial injustice we've all seen how do we process all of this one can argue that another discipline that of humanities and particularly the use of narrative has a unique role in laying out these issues and helping us contextualize all of the data which can be dangerously bloodless for that we're lucky at ucsf to have a group of faculty and trainees who've done pioneering work in this area we'll hear from emily silverman who's a faculty member at zuckerberg san francisco general hospital who a few years ago launched a storytelling effort called the nocturnus which she's used really converted over the last six months to focus on covet both through live storytelling and through podcasts along with emily we'll hear from another of our faculty members ashley mcmullen who's based at our va hospital a few months ago ashley launched a podcast within the nocturnist called black voices in healthcare to explore uh the unique issues that we're all uh thinking about and struggling with around racial violence racial justice and how it all syncs up with covet so this segment which i'm really looking forward to will go from about one o'clock till about 120 125. so with that we have an ambitious and wide-ranging program i hope it gives you a sense of the role of creative new thinking in attacking this pandemic so we will get started with michael minna and a new approach to testing all right well thank you so much for having me here it's it's great to get an opportunity to uh to talk in this grand rounds uh so i'm going to be speaking today about covet 19 testing strategies uh and how we can use testing uh for surveillance and and more importantly for control of epidemics uh that extend beyond how we normally think of of coven 19 as a as a tool for diagnostic purposes so i like to start out with this slide here just to drive home if anyone continues to think that this virus might be disappearing sometime soon the future doesn't look so grim if we look to what we have known in the past based on seasonal coronaviruses the the future starts to look a little bit as we move into the fall and winter we are very nervous that we're going to see increased uh cases of this virus so these are seasonal coronaviruses that i'm showing on the two slides on the right here and on the left uh it's a little bit out of date at this point but just to show that of course we all know cases are continuing to climb for this virus on the right are are what we know of the seasonality of of normal coronaviruses that are traditionally circulating in the human population and what we can see here more than anything else is that there are massive spikes in coronaviruses they usually come around uh november and december and uh and so if if we don't yet know what exactly this virus is going to hold in store for the winter we don't fully understand and appreciate all of the underlying biology that goes into driving these dynamics but i think that one of the major takeaways here is that we need to continue to act now to be prepared for what's going to potentially happen in the fall and of course further into the winter to lay some groundwork for what type of surveillance and outbreak control testing i'm discussing i just want to point out briefly that there's of course two different types of tests each of these have multiple branches within them but there's testing for the virus and then it's testing for antibodies the virus testing for the virus is extraordinarily important if you're trying to use it as a modality to contain and control uh outbreaks and stop transmission chains uh when you know that outbreaks are occurring and this is because you have to be able to identify people who are infectious and ask them to stay home for example and not and serve to stop the spread at that level antibody testing is an extraordinarily important tool from a public health perspective and it is one that is has been traditionally used for monitoring uh outbreaks and pandemics and epidemics and things along those lines uh but because the antibodies uh usually develop a week or two after somebody uh has started to present symptoms generally they are not going to be useful as tests to stop transmission chains at their source but they can be used as very powerful tools once population prevalence is low for what i call peacetime surveillance to keep an eye on a community large communities to be able to know where outbreaks are are emerging and then you can jump in with virus testing and other non-pharmaceutical interventions or pharmaceutical interventions to try to mitigate the spread so uh for the rest of this talk i'm going to be talking about virus testing and uh despite talking about sort of these rapid tests that i'm that i'll discuss at one point um i just don't want people to confuse them with the with the rapid antibody tests that were being uh build back in april and and march but turned out to some of them turned out to not be such high quality so if we think about test characteristics uh we usually think uh about um test sensitivity has been sort of front first and foremost in a lot of the discussions surrounding testing for covid of course specificity is also part of this framework as well i'm not going to talk too much about specificity uh certainly if there are questions i can i can discuss those but then cost which i essentially like and cost to frequency of being able to run the outperform the test and then speed to get the results back how long does it actually take what's the turnaround time for the time somebody actually gets the swab stuck into their nose to the time they get the results our priority has definitely been in this country anyway sensitivity first and foremost and then cost and as we all know speed has been abysmal lately uh with with some people waiting numerous weeks to get a result and and as far as i'm concerned from a public health perspective if you're waiting more than a few days that result starts to may as well just be thrown away in a lot of regards so a fast test that might give results in minutes and that is very very sensitive uh is likely going to be expensive and we're seeing this with tests like the abbott id now and the quadell and bd variatory these are tests that are going to work well they're going to pass fda ua approvals uh they're going to be true diagnostic tests but they're also going to be limited they require instruments that cost hundreds of thousands of dollars and then they are going to have individual cartridges that are very highly manufactured and are also going to increase the price which is going to necessarily decrease the frequency that they become available to population but what about a test that gives very fast result results is inexpensive could be used truly daily by most people but is a thousand times less sensitive at the molecular level does it matter and and the question is extraordinarily important because these tests can be available today and so to answer this question we have to really look at what happens within uh the body uh and uh in terms of virus growth so normally what a physician sees when they get a result back uh for a patient with coronavirus is that they'll see uh they'll see something along the lines of positive or negative it doesn't come with much more information and this has been i think a real travesty of how we are uh reporting our results i've written about it in the past and we'll have new information coming out about it in the future but essentially i feel very strongly that we should be giving clinicians from the laboratory uh ct values even if imperfect and not uh they are still very valuable uh the ct value is of course inversely proportional to the virus concentration and what we know about this is that uh as somebody gets infected there's usually an incubation period where even the most sensitive of tests available today might still show negative once somebody turns positive with what i'm calling here is a high sensitivity test or we might think of it as the the gold standard qpcr test uh maybe they're just there their viral load is around 10 or 100 viral copies in that swap but very quickly at that point the virus is in sort of what we would call deterministic exponential growth it's growing very rapidly and within hours maybe a day or so the virus will blow through many orders of magnitude as on its sort of steady march exponential march upward and viral load and it will pass the thresholds of even a test that is a hundred times or a thousand times less molecularly sensitive than a viral pcr test and it's at about that time that somebody actually starts to be able to transmit the virus and so this is really important because uh the differential between the high sensitivity and what has been called in the media and elsewhere a low sensitivity test is actually a matter of hours and maybe a day but it's not a particularly long time at that point people are transmitting the virus and what we normally find when we're measuring um and finding that a test is low sensitivity is we're actually measuring down here in this yellow p this yellow period of time when somebody has actually for the most part cleared their virus and there's a lot of viral rna that's just continuing to stick around inside of the nasopharynx it could potentially uh be we're not quite sure what exactly is is leading to this it could be some very low uh level replication potentially of non-modifical virus but either way we don't believe that it's transmitting uh in general this is even by the cdc's own admission that after about 10 days it's not worth testing people anymore because they will still oftentimes be positive but but will no longer be transmitting virus and they could probably leave quarantine and so this is uh the dynamics here are very important because what they suggest to us is that most of the uh loss in sensitivity that we're getting when we evaluate these different tests is really happening at a period of time that from public health perspective saying nothing about the diagnostic use but from a public health perspective would probably not be very valuable to help with transmission chain mitigation and stopping transmission because people are already done with their transmissible period anyway so if we take all of this information we put it into population level mathematical models uh which we've done with a number of different uh frameworks what i'm showing here results from an agent-based modeling framework the two different colored bars are what we would call the pcr test the high sensitivity test and then the darker bars are what might be thought of as a lower sensitivity test and we've done this with a hundred times worse sensitivity a thousand times or ten thousand times lower molecular sensitivity and what we see is by far the most important piece of of the testing regimen that we need to get right here is not the exact metrics on the test itself if your goal is population uh mitigation of transmission but it's the frequency that the test is being used and if we can use a test every day or even every three days the actual uh the actual requirements of test sensitivity uh are are play only a very very minor role and what we can see uh on the right here is that relative to a scenario where you just let the epidemic sort of move move through the population with no testing and you just have people quarantine when they feel symptoms what we can see here is that if you test with either of these tests daily or every three days you will essentially stop essentially all transmission at the population level over the period of time that the epidemic would progress as we start to move out to weekly or every 14 days we start to have a much more difficult time controlling the epidemic through testing strategies and so what this is really suggesting to us is that uh sensitivity is should really take a backseat to frequency uh when it comes to testing as a as a public health tool uh we can also look at the turnaround time of these tests and what we see is that uh in terms of turnaround time where i have again the frequency of testing are the big groupings uh daily three day weekly or 14 day but then the zero one and two is how long does it take to get the result back and that's very important here because a lot of testing when we did this we hadn't even had it in our minds that we might have test results getting back to people seven days later what we can see is even at three day testing if you're not getting the results back within 48 hours you're really losing a lot of opportunity to prevent infections at the population level certainly once you're at weekly testing if you're spending 48 hours to get the test results back then you're you're barely able to reduce the the epidemic and to put this in context this is weekly testing of nearly 100 of the population and this includes a lot all the variation and sort of our ability to detect cases and all of that uh but in the us right now we're not doing anywhere near testing of the human uh of the population of the us weekly uh we we are we're running around 800 or 900 000 tests a day across the us which doesn't come close to any of these scenarios uh so we've been really pushing for a whole different way of thinking about how to produce tests that doesn't require laboratory uh that don't require laboratory sort of testing or these very high sensitivity tests but can we actually get lower sensitivity tests that will give you results back uh here in this case where we have zero that would be the equivalent of giving results back in 10 or 15 minutes to somebody and they could use it for example every day as they're brushing their teeth and so i think to really to prevent outbreaks across the population these results suggest to us that it's more than okay to sacrifice molecular sensitivity for high frequency uh testing which would ultimately be much much better to uh detect infections and so i think that we should really start prioritizing cost and frequency much more so than uh sensitivity in terms of the tests that we're deploying but why don't we have these tests today unfortunately all of our tests we don't have a public health framework in this country public health has been largely ignored for clinical medicine and uh and in this case i would say that we we have this situation happening where we we just don't have the framework we don't have the regulatory pathways and frankly we don't have the language to even consider a test whose primary objective or which primary objective is one of public health and not individual health and uh and so because of that at the fda for example it requires 90 sensitivity uh which is really based around uh compared to pcr which is based around this idea of diagnostic medicine and what i'm showing here on the bottom right are the ct values from the last eight weeks in massachusetts and this is very very important because what we can see is the ct values from the last eight weeks that is at the you know these aren't fully across the whole state but what we see is the the vast majority of specimens that were collected had ct values well above 30. so that means the majority of tests that we're actually detecting people as positive are probably well beyond their period of transmissibility and are in the recovery phase of their infection so and this is because we're not doing frequent testing so we're only capturing people what i have here in this long tale of pcr positivity which is past the period of transmissibility so what we're calling for is really to frequent daily testing which would uh almost guarantee that you detect most people on the first or second day that they are transmitting virus versus a very sensitive pcr type of test which is performed infrequently with uh the most likely scenario being that you miss people altogether at the very least you you miss their transmissible period and then you end up quarantining them erroneously and sending contact tracers down rabbit holes that they don't need to go go down because uh they're looking during the wrong time period anyway um so i think that it's important to point out that there's different sorts of rapid tests uh there are the the what i consider as the nespresso machine model of tests and these are the tests that are essentially could could get to the quality and reporting structure that the fda currently wants for at home tests these will be things like that are already available like the bd veritor the quadell instruments but they're going to be expensive uh they they might work extremely well they might be able to report back to authorities and give negative and positive results on a daily basis but they're necessarily going to be limited however these are what the fda currently wants what i want to see is that we get the instant coffee version of these tests where we have a test that we can produce in the millions that won't be limited by the ability to produce the instruments uh they might be a little bit lacking in their molecular sensitivity but the trade-off is that you'd get to use them every single day and and so this is really where where we're looking at in terms of rapid antigen tests today uh and unfortunately what we can see is uh uh this hasn't really been picked up um at the level of the fda at this point uh what we can the bret gerard recently said that this would be catastrophic if we do if we release tests that had only 30 percent the sensitivity of pcr but again pcr uh the majority of cases that we're finding are past the creative transmissibility and most likely these rapid daily tests will be much more sensitive than that to detect people when they are transmitting virus and to put this all in context what i have down here on the bottom my best estimate is that currently with our with our surveillance networks that we have set up we probably have around a three percent sensitivity to detect cases in the us right now and time to act on those cases and uh and so currently this is what we're dealing with and i think that if we can get to 80 sensitivity or 90 to detect transmissible people uh and ask them to stay home then that would be a huge gain that would most likely prevent outbreaks so i can uh i can stop there and i'm happy to take questions perfect thank you so much that was terrific uh i'm a little bit unclear on whether these tests exist today or don't do not call the nuts test so these tests can exist today they do in large part in fact you could we could just take the example of the bd veritour system underlying that system is actually a rapid paper strip antigen test but in order to improve the sensitivity sufficiently to get it fda approved they had to essentially have a reader read it out it's there's no chemical modification happening inside of that it's just purely a reader and they have to put it into a plastic cartridge but technically underlying it it's just a paper strip test uh there's the sd biosensor and the raphogen test these are both made in korea they seem to work very well i haven't evaluated them myself but they have ce uh they have been cd marked in in europe and so these tests can be available and then there's a few other companies that are starting to make them today as well and uh so so the short answer is is yes the what i would add though is is these can essentially i don't see another solution at the moment we're not going to get vaccines tomorrow we aren't going to clearly the the the mechanisms that we're using currently to try to control those viruses aren't working in the u.s and and i do think that this is simple technology it's lateral flow assays that have been around for a very long time and this is the kind of thing that we shouldn't be asking do the companies have them ready to build at this point we should be saying you know how do we get the federal government to just use uh all of their might and all their resources to just start making these and for a fraction of the cost of the most recent stimulus bill that was passed for coronavirus response we can have every american using one of these every single day for a year that's your your vision is i wake up in the morning and i test myself and if i'm positive i stay home and if i'm negative i go out and do my thing yeah i like to think of these as transmission indicating tests or transmission blocking tests and and they are you still would act the same way that you'd act otherwise in terms of uh wearing a mask social distancing whatever is your normal routine the only thing that will change in this case is that you if you get a positive signal you you don't go out would you envision i mean as you say one of the things that you're doing here is trying to push us to abandon in some ways the medical diagnostic paradigm to a more public health paradigm the medical paradigm would say all right we screen with a less sensitive test and then we do the better test if you're positive is that part of this or you abandon that idea as well no i'm not i wouldn't want to say that we abandoned uh any bit of the diagnostic infrastructure that we have diagnoses are still crucial if you're a physician and you have a patient sitting in front of you who has signs and symptoms of of coronavirus absolutely you need the the absolute most sensitive specific test that you can get uh in this case this is uh what i'm trying to suggest is we create a whole new way of thinking about how a test can be used and viewed that doesn't have to do as much with individual health but this is a test whose primary outcome is population health which uh you know as far as i'm concerned if we can reduce population incidence of this virus then everyone's individual health becomes much better and people become much safer and so i think that we need to keep the diagnostics in mind and we need to um start really changing the message that this is not a diagnostic test and it is a whole different way of thinking about what a biological test could be and and maybe we have to think of it almost as a as a as a biomass or something along those lines where uh they don't need to be perfect and uh in many ways this reminds me a little bit of of what happened with masks in march and april uh where people that the general theme was if it's not an n95 don't wear it uh you don't you know we couldn't trust people to uh to not feel a false sense of security and of course now we say if you have anything that repre that looks like a mask at all wear it um and i i want us to get to the same point to recognize to just come to grips with the fact that we don't we're not going to diagnostically test our way out of this uh epidemic and in a new way this is just a it is a test that people are using but it's really should be thought of more as a way just to block transmission in the same way that we think that a mask can be served to block transmission even if imperfect and it seems like i mean part of the paradigm here is that even though it is less sensitive it is perfectly sensitive enough for what you care about which is are you infectious first of all is that right and second of all is there a correlation you didn't talk about the degree of illness or or how likely you are to get very sick is that also true if you if you ping positive on this test you have a higher level of virus and not only are you more infectious but do we know that you're actually more likely to get sick or do are those things things in sync as well well we've we've recently looked at a lot of data of our ct values from symptomatic and asymptomatic individuals we haven't seen a big difference between the ct values of the two so i don't know that i would want to go down that road and and suggest that uh that it would be indicative of that what we do know is that most people who get infected with this virus during their viral replication and their growth period of the virus in their body they generally surpass the uh exceed the limits of detection of these paper antigen strip tests so i think that they would do a very good job at capturing most people in the first day that they might be transmissible or even the day before they become transmissible if using it every single day and the reason why we we don't want to think of it as a diagnostic is if there is somebody who who gets infected with this virus but manages to essentially control the virus in in in large part never gets to a place where they're where they are potentially transmitting it then it could be that these transmission indicating tests never actually turned positive for that person so it's not really a diagnostic but the good thing is that most people who would be transmitting in particular super spreaders will probably be spewing out a huge number of viruses and and these tests will turn positive and and to to put it in perspective the pcr test detects people uh detects virus down to around 100 viral particles per mil people that when when we look at the the range of which people um have virus in them what during transmissible periods it's not a hundred and it's not a thousand it gets to a hundred million a hundred billion or trillion viral particles so all of our discussion about sensitivity has all ranged at this 100 level you know 10 to 100 viral particles when the real importance when it comes to epidemics is is detecting people probably above a million viral particles or more so just to get a little more practical uh you didn't talk about the mode of collection am i spitting on it and and then the mode of reading am i looking is it a pregnancy test equivalent am i looking for a color change and then you didn't you you implied it's very cheap but are we talking about you know a quarter a day a dollar a day five dollars a day any any sense of that yeah so the mode uh could be saliva and i know that uh there's different tests that are being developed some use saliva and some just use an anterior narrow swab uh into saline so i think of it as kind of the complexity of taking internet contact lenses maybe you have a little squeezy bottle of saline that you that you use every day and you put the swab in there and then you drop the little paper strip in capillary action pulls it up and just like a pregnancy test yes you look for a line to turn a color my expectation is that these should be around a dollar a day i think that they can be produced for less than a dollar a day if the big companies get involved or if the us government takes it over and starts producing them and so a lot of people say well that's 300 million dollars a day for the united states you know that's totally absurd we can't do that but when you start talking about what we've spent with coronavirus 300 million dollars a day for a full year of daily use by every american almost is ultimately is just a small fraction of one of the stimulus bills that has been put forth so i think it's fully doable from a financial perspective has any country in the in the world embrace this idea and is using it today uh so not yet as in this way and i think uh this whole idea of truly daily testing to stop transmission chains and really serve as a use testing as a transmission blocking agent uh we came out with a study about a few months ago that kind of pushed this what i shook some of the results from uh and that sort of i think in general started some of the conversation or at least started to accelerate the conversation so since then and since we've been gaining some more traction in in the media and congress and senate and things uh we have been hearing more and more uh countries wanting to get involved and so on any given day i'm getting calls from prime ministers and princes of countries and things from around the world asking how do they get the tests and how do they start using this tomorrow unfortunately my response continues to be well most of the manufacturers that could be producing them aren't bothering to at this point because there's no clear fda approval pathway but sd biosensor and raphogen are two two korean companies that are starting to really scale up production and i believe senegal might be starting to do it and we've been talking with a number of different countries about uh about carrying out these types of uh studies or these types of programs today when you hear about ball players or you know visiting the president that kind of thing using rapid tests none of it none of them are these they're still fast versions of of the more sensitive tests so this would really be a change in in paradigm yeah exactly uh so it seems like you've gotten a lot of tr i hadn't heard of this idea until a couple weeks ago it feels like it's gotten a lot of traction are you uh are you hopeful or not in terms of in terms of uptake and sort of maybe parse your answer of uh from the rest of the world and then the united states uh i think uh the rest of the world could certainly much of the world has many fewer regulations they have a greater sense of public health as a goal in mind um and i think that these things could be rolled out uh in many parts of the world as we speak and they are starting to to be um in the u.s i think that i'm i'm hopeful that we will get there we've gotten a small army of senators and congressmen involved and very interested uh the media has certainly been very interested in putting applying pressure and and um uh the nih and the and and cdc have both been at least from you know heads of those uh or leaders in both of those uh organizations i've spoken with have been very very supportive and the question is okay well how do we how do we move it what needs to happen and it really comes down to the fda and unfortunately the fda is the regulatory body for these types of tests but they don't have a remit to to evaluate public health tools so there either needs to be a whole new pathway at the fda to to say okay this is a pathway that you're going for a public health claim and not a diagnostic claim so it won't be health insurance reimbursable et cetera or the fda needs to say this is a public health tool they wash their hands of it it's off their desk if that happens which is not what i'm hoping for i'm hoping that they that they want to keep uh control of of authorizing them but if it does happen that they say this doesn't fall under our purview then very quickly we need the cdc or the nih or some other authority to come on board and say okay we're going to create some sort of certification program because the last thing we want is for the market to become flooded with with tests that really don't work and how this program fail so i'm hopeful that the fda will decide that it's that it is within their purview to create a pathway to evaluate tools whose primary goal is is one of public health instead of individual diagnostics is there any analogy that you can think of in kind of the world of public health where there's there is a tool like this and we figured out what the regulatory pathway is for that um to be honest not really um you know at least not tools that are regulated so thermometer testing is i guess you know in the sense of covid people are using it as that it's not a good alternative masks um are a are an analogy i suppose but but in our in our culture in our language the moment it's a test and not sort of a mask kind of thing you know it becomes seen as a diagnostic and i i've been trying to rack my brain if there is an example maybe rapid hiv tests would be the closest and i would say that there is a sense in the hiv world that that you getting your own by giving yourself an understanding of your status is really a public health good and and it allows people to make better decisions about their actions and and that's kind of what we're going for here as well yeah well thank you for pursuing this line of reasoning my senses it i don't know how much traction would have gotten and except for the delays i mean it feels like if we could get two-day turnaround on old-style maybe overly sensitive tests i'm not sure uh the the market for an alternative way of thinking about this would have opened but it clearly has now i mean this current situation is disastrous and so that creates an opportunity to think about this in a new way and i really appreciate you helping us to do that good luck with it yeah all right thanks so much really appreciate it let's switch over to trevor uh bedford who will talk to us about herd immunity a loaded term if there ever was one one that's been hotly debated throughout the course of this and trevor's been doing some really interesting new thinking about what it means now that we have more experience with covid so trevor thanks so much thanks bob um and thanks for the opportunity to present here i have to admit that this is going to be a bit rougher than maybe most of my talks so um really most of my research focuses on genomic epidemiology and evolution of viruses such as star skill v2 um this the specific angle on population immunity or herd immunity is kind of pretty basic uh look at infectious disease dynamics and kind of what kind of maybe some more obvious things that we can see from the data here um but hope it's still interesting so um oops there we go so um there's this very classic conception of population immunity and the effect on transmission where we'll have the r naught of the virus that i think people are going to be quite familiar with it's going to be the number of secondary infections that one infection causes for sars cov2 for covid19 we think that's somewhere between two and three so i'm going to be using 2.5 for the r naught throughout the talk and then what happens is that that infected individual is going and meeting random people in the population and so the number of actual infections that causes depends upon meeting susceptible individuals as opposed to immune individuals recovered individuals so the um number of secondary infections caused a particular point in time will be r naught times the fraction of the population susceptible so very simple equation and what this means is that more and more of the population are immune rt drops and drops and this is where we get this normal 60 herd immunity threshold that is the normal number that people uh throw out when they talk about herd immunity and so this would suggest that yes that if we're populations acting in such a fashion that that rt is 2.5 that we would need 60 of the population immune to uh to suppress the transmission and so we can kind of see this see this effect here in a very simple simulation this is this kind of classic sir model just as a just as a demonstration where we start with 100 of the population acceptable we have an epidemic happening here in red and then as that occurs we move individuals from being susceptible they get sick and then they recover and they have immunity this is important and then over time the recovered build up and acceptables deplete and we see here we have this peak of the epidemic here that occurs again in this case when we have 40 percent of the population that is um is uh still susceptible and we can see this here as well that our t drops over the course the epidemic um first 2.5 then it goes below below one as we're falling here and the very peak is going to be where rt equals equals one and so this is this very classic picture here uh however uh in the case of of covid as well as other diseases human behavior plays a huge role in determining transmission so our knot is not fixed and we we have a massive ability to to modify this to modulate this early in the epidemic once we kind of knew that things were spreading we saw this immediate um strong reduction in mobility people staying home lockdowns et cetera and then we were um we and others this is work from ibm um in in washington state looking at early on in the washington state epidemic if we look at mobility um from google facebook et cetera compared to rt estimates there's this really nice correlation early on where there's the strong reduction in mobility and a strong reduction in rt and so just following that up a bit if we go from say march to uh to july and i'm going to really throughout the talk focus on three different states to just make things clear florida arizona where we've had the recent surges and new york is kind of a comparison here and so here if we look over the course of march we had this really large epidemic going on in new york we still have increasing caseloads in florida and arizona new york starts to decline over the course of the course of april to june we have this plateau in florida and arizona and then this uptick later on in in june and we can look at how this affects rt so we see early on that we get this like two and a half level that we'd expect perhaps even three where there's this really rapid amplification behavior starts to change rt really strongly drops we are starting to suppress the epidemic things are going down but then in the states that reopen earlier on in arizona and florida rt starts to take up again and so we have um in may and june going above one and we start to see these these epidemics because of that um if we look at societal responses again we can see this is just a couple of my my favorite things to look at one is open table reservations just as a measure of how many people are going out to eat at restaurants we see this immediate dive in restaurants in all three states and then the two states that start to open up this slowly climbs again similar effect in google mobility for people looking up directions to go to retail and recreation and we see this again this huge dive and then a slow tick up after that point and this pattern um fits with effects in rt so this is a phase plot that maybe some people are going to be familiar with where we look at two different variables and see how they change over time so we have early on rt is high and a lot of people are going to restaurants and then over this first phase there's a rapid decline where both rt and going to restaurants drops and then a very slow increase again over here and so um we don't get back to the same point um because there's other things going on masks people being more cautious in general but there's still then this correlation here between societal behavior and rt we get a similar picture in google mobility where there's this immediate mobility drop followed by a mobility increase as kind of things start to slowly come back online and so uh i think it should be obvious and agreed upon that the way that we're behaving society will affect are not and affect and change our t values this just seems very clear and so uh what we're left with then is we start to kind of now add back in immunity here that if we wanted to get to rt i have this very simple equation um of we have the innate or not we have this alpha parameter which is going to be basically societal social connectivity how much we've suppressed um connect social connections that are uh possibilities to spreading the virus times the fraction susceptible and so the important thing here is that let's say through um through reducing social connectivity our rt is 1.4 rather than 2.5 if zero percent of the population is immune then as we build up immunity you get to this herd immune threshold at about 30 percent of the population infected rather than 60 and if we have stronger societal social control of the virus and we have a rt of 1.2 we need less than 20 immune to reduce the spread of the virus and to control the spread of the virus and then of course if if we can otherwise we can just control things completely by by social behavior and the other way to look at this and i think this is maybe the main figure of the talk is that that this is just the same exact equation very simple thing we're looking at here that we could have something where if we behave um 100 as we were in january and we don't take any measures to control the virus socially then we really need to be to get to this blue regime where things are suppressed we really need sixty percent uh immune but there's this line here that as um as we reduce social connectivity um we need um less and less of the fraction pop the less and less of the population of union to still control things and so we can get to these these sorts of regimes that i think we're actually starting to hit in states that have had um have had a lot of spread so if we look at florida for example my guess is that we've seen between 15 and 20 percent of the state having covet at this point which is in some ways really a big number and kind of shocking but i think it's actually what's what's true so we've had 550 000 confirmed cases in a population of 21 million we ex from other serology work that's gone on we expect to be catching perhaps one in five or one in six infections as a case this is similar to kind of these issues that um that michael was talking about and this is going to be 10 days ago because we're registering things that are not are not completely recent so we have about 3 million infections were 14 in the state 10 days ago um this is um a really um probably my favorite um a bit of modeling here where this is using a one to six ratio estimating today at this point we have 20 percent of the state infected so it might be 10 but um but whether it's 10 percent or 20 is not actually really the the main point here uh so if 20 of the population has recovered and has immunity we can behave as though rt is 1.25 and we still get an epidemic that no longer propagates and so we were talking about this kind of pretty narrow range of rt this becomes important and just as an idea of what might be happening here that if we kind of go forward a bit farther and we look at closer to the present we've seen a slight drop in florida and a more substantial drop in arizona in their in their surge of just confirmed cases and so these drops have been quite recent if we look at rt that places rt dropping below one at the beginning of july roughly for these for florida and a bit earlier on for for arizona and i think um and then so if we look at societal responses so again this is open table restaurant reservations versus google mobility we can see that despite this really strong surge in um in florida and arizona there's not a lot of obvious differences in how people are behaving we get we get this dip from june to july which corresponds nicely with this step here but then we see continual declines in july that are really not borne out by the data we actually have people kind of returning to restaurants in arizona and then a very flat google mobility estimate here this doesn't include things like actual mandating that bars close that mandating of mask wearing etc so there can be other factors going on in this july period that are not being captured by people going out to restaurants and people um going to searching for retail and recreation on google but at least as far as that goes we don't see kind of further reductions here and so because of this if we look at this phase plot we see kind of things going up as we'd expect with rt versus open table as kind of things come back online we start to see this epidemic surge uh people um go to fewer restaurants and then it declines a bit but then now we've had this recent period this last month where rt has continued to drop despite there actually being again an increase in um in use of opentable and then a similar picture for google mobility especially in arizona where we've seen this continued decline despite despite not not changes mobility so the speculation and i think i believe it expect speculation at this point is that at least um some of this uh the continued decline that we're seeing is due to buildup of population immunity and again that we don't need we don't need much so we've seen a drop of rt from about 1.3 to about 0.9 somewhere in this in this framework and if we've gone to a um uh 10 20 of the population uh recovered in these states that would suggest that maybe 25 percent of the reduction in spread is actually from immunity and maybe 75 percent is from um is from these societal changes and so this is not um this is her community is definitely not the goal and i'm not i'm not at all proposing this ifr is still something like point five percent getting to twenty percent of the population having had covet it still bears this massive health cost so that's not that's not at all what i'm intending here but i'm just trying to explain why we've seen these epidemics wax and wane and that the idea being that if a region fails at suppressing the epidemic through these societal means we're going to expect that as the epidemic occurs we'll build up some population immunity and this will be a natural repercussion to kind of kick in and help to control things a bit at the kind of levels that we're looking at and so um that's it i'll stop there and take questions great thank you trevor it's this is going to test my math ability but let me uh throw a few questions out out your way uh is there some natural homeostasis or equilibrium here that as places begin to get better they naturally let down their guard and therefore if you're kind of making projections based on some assumptions about behavior it almost sort of auto regulates in a bad way as soon as things get better they will be acting worse yeah i think i think that's a really good point and from the beginning um that's been my statement that i can like i can predict how the virus is going to behave much more than i can predict how people are going to behave um so here yeah so you can imagine in this regime where 20 percent of the population becomes immune that helps to suppress things now that that state um sees that there's not covid circulating and so now you do the next you ratchet things up and you open up schools or you you do the next thing and then that will then kind of push behavioral rt up and you'll have another kind of another epidemic until you've reached this new this new equilibrium point i i think that's um yeah that's very much the worry and you say i can predict the way the virus behaves better than the people but you can i think now six months you probably can begin to predict the people you see what people have begun doing in new york would it say that they're going to get hit again in new york in the fall because they they appear to be forgetting the lessons of march and april or that they're you know 20 of 25 of the population being immune should be enough to keep it down even if there's some recidivism and behavior yeah um it's hard to completely it's hard to it's hard to model this in that we could say compare new york to chicago or something like this this as as we have the seasons change here and we're going to expect more population immunity in new york that will help to hold things down but we could also imagine that people in new york have a much more visceral memory of of how bad things can be and so even if you're not kind of capturing things completely and mobility data et cetera you could imagine that new yorkers are behaving more carefully than people from chicago and so um so it's hard to exactly um pin that down but you would expect if if this 20 percent of the population um possessing immunity does have an effect that new york will have less of a chance of a um of a or a smaller ability to have a second wave this um this fall than say chicago yeah i mean i also note that for example an open table reservation is not all the same i mean you know paper reservation in february was you're going to sit in a crowded restaurant you know shoulder shoulder and an open table reservation in new york may very well be sitting outside you know 25 of capacity whereas maybe in arizona it's still you know it's it's still not all that different than it wasn't february so some of the metrics of behavior seem they might be kind of imprecise yeah i i agree and it does seem that you can actually um have have economy society being pretty open and doing a lot of behaviors um going to restaurants outdoors et cetera and things are kind of working pretty well um and that doesn't bring rt back up to 2.5 you get to like 1.4 or 1.3 or something like this um with things being quite open because yeah because of exactly these these mitigating behaviors that people are adopting and the model looks like it's uh you know a person is a person but you can imagine my you know my parents are in florida and they're 90 and 84 and they're basically under house arrest i mean they're acting very differently than a 25 year old in fort lauderdale and so how does that i guess maybe one would say they're equally susceptible it's just that if my parents get it they're in for a much much more likely to have a bad outcome but does the susceptibility change at all based on differential behavior by different populations based on their perceived risk yeah that's that's a good question uh so we have seen um a clear shift and i um i think most people would agree with me here we've seen a clear shift towards a younger population being being infected in um say july june july august compared to march and april and i've i've thought of this as just people behaving somewhat rationally in terms of their own exposure to risk and so it makes sense that there's been this this shift and that's that's slightly lowered um ifr and it's had these these sorts of repercussions so people don't know so what do you explain what ifr is true yes um infection fatality ratio and so early on if you if you look at new york that was over one percent of the um infections um uh people that were infected died the there are two difficulties in uh estimating uh ifr one is that not every confirmed you don't capture every infection is confirmed case so you need that kind of zero prevalence or something to be able to go from cases to infections evan ii is that there's this big lag between um when cases are reported and when deaths are reported uh there's a shorter lag between people actually dying and then a longer leg between the the kind of reporting coming in and so it makes ifr a bit um a bit harder to estimate but at this point i do think that it's it's decreased nationally compared to um march and april um partly due to better clinical care but also due to this just shift in age distribution does that change anything in your modeling if if if if the behaviors actually are quite different for older at-risk people versus younger less at risk people maybe transmissions are the same but the ifr i assume would continue to go down and again you wonder is that going to be cyclical people say oh it's not so deadly i'm going to go out and party again yeah it's also a good question so um so wait sorry repeat your question i've i've now i'm just i'm just thinking that of the the the uh the fact that you know people are going to act differently based on their perceived and probably their actual risk of having a really bad outcome yes okay so yeah how would i i think of that is like this the best way to model it which i haven't done much of and it would it would take some some more careful thought careful work uh is basically uh you'd want to start to have these compartmental models where we have um perhaps a younger compartment in an older compartment and you you start to break up the population and we think that the the younger compartment will be having a kind of a higher behavioral rt than the older compartments and then you want to try to measure mixing between those and and so forth and you probably want that sort of thing as well for things like the difference between northern florida and miami dade county where we're going to expect kind of a higher our higher behavioral rt in these urban areas that will get but that will get you to a larger fraction recovered a larger fraction immune so your equilibrium point will be a bit kind of a bit farther off compared to the um the more rural areas of a state i've seen some pushback on twitter not surprisingly about this uh you know how if you're saying if someone can distill this message down probably overly simplistically to all right we might be hitting a version of hurt immunity at 20 or 25 percent how do you explain san quentin prison where 60 of people are infected or some of the data you hear is coming out of some of the schools or you know even early cruise ships where you assume there was some behavioral mitigation that started reasonably quickly and yet they got up to numbers like the 60 that's kind of the classic herd immunity threshold yeah um so again i think the the argument is that um that rt on the behavioral side is is very malleable and is very um context specific so if you have a situation like a like a prison uh there's there's not much you can do in terms of um of behavioral mitigation of spread and so you'll naturally have that um if we that slide of the heat map you're going to be kind of high up on the y-axis for um for social connectivity and you can't you can't really modulate that so you'll expect that your epidemic will be much larger and we see that in other places that definitely like in bergamo for instance where we have sort of prevalence of like 50 um that cities in italy yes um that that we definitely have cases where you can get a large fraction of the population infected um but um yeah but the i but i think this plays in where the idea is that there are going to be these settings or populations where where there is less reduction in social connectivity as you have larger kind of larger prevalence in those areas and if you have this um this mixture like we're seeing in say florida and arizona we get to some kind of intermediate point in both in both behavioral rt and population immunity so maybe my last question so you've got a ton of twitter followers you put that post out there uh as um as soon as you say heard immunity you know it's it it pushes a hot button in a thousand different ways probably like playing masks or saying trump or something you know anything it's gonna a lot of people can react so first of all what what were you trying to achieve as you put out this theory and has some of the pushback been interesting or surprising to you yeah i think basically i don't want it to me it seems clear that we're going to have some effect of population immunity that that is that is helping control things what that actual that actual number needs to be needs to be dialed in and quantified but we're seeing a a um we're seeing the epidemics and the surge in florida and arizona subside and i think that and it might not keep going it might kind of get to some slightly lower fraction uh but i think it's important to try to understand and convey what what we think is happening and that um that that there's some yeah that that it's not just kind of magic that uh that we've had these this epidemic subside in these these places it sounds like not just magic but also not just that people changed behavior but that that even though you're not at sixty percent you you there's some aspect of heard immunity like like being like the the concept of heart immunity is playing out in some important ways even though you haven't reached the classic threshold i guess is that that is that yeah yeah that's fair and i think the um the pushback is basically um either that a um herd immunity threshold is 60 uh period but you're wrong um or um or b um you shouldn't say that because it will encourage people to um to to behave more less carefully yeah what do you uh that seems like an obvious pushback what how do you respond to that um i i think from the beginning i've thought it that like this this feels like the same thing playing out with masks early on where if the if you're if what if you what you want people to do is to not buy up all the n95s so that they can be used by um by health professional healthcare professionals um it it kind of is self-defeating when you say that masks don't work and then as the strategy to to have that um that that desired outcome and so i think kind of being as scientifically open with with people is is the right way to be behaving in these um in this sort of um yeah pandemic and trying to try and have as accurate and transparent public health messaging as possible great well thank you for doing that i think it's it's been provocative and certainly helped me think about this in a different way and yeah it does feel like when you look at those curves and how they've begun to come down you certainly get the sense of something more going on than just purely behavioral change and i guess we'll see how that plays out over the next several months so trevor thanks so much keep up the great work and look forward to hear your thinking on this okay thank you last uh last segment and uh bring on uh emily and ashley i'm not sure if you're both coming on at the same time or just emily first but i know emily speaking first all right emily the stage is yours [Music] all right thanks so much for having me my name is emily silverman and i'm an internist at zuckerberg san francisco general hospital i'm also the founder of the nocturnist which is an independent medical storytelling community that i actually started up when i was a resident here at ucsf and i'll be talking for a few minutes about the project i've been working on over the last few months called stories from a pandemic and then after that i will turn the mic over to my colleague dr ashley mcmullen who's going to speak about a similar audio series that we're working on together called black voices in health care so before i dive in i just wanted to provide a little bit of context about the organization that i run which is called the nocturness so the nocturness was really born out of the burnout that i was experiencing during residency as i feel many residents and even attending physicians are experiencing today really just feeling like i wanted a space where healthcare workers could come together and examine themselves pause take a breath find space to explore find space to play tell stories about ourselves tell stories about our work and uh in january 2016 we did our first live show with a very very small audience of 40 people and picked up a lot of traction i think there was just a lot of hunger in the medical community to be engaging with ourselves and with our work through this more humanistic and narrative lens i think especially as computers have been encroaching on the doctor-patient interaction and just feeling like sometimes medicine can be really creatively stifling which is unfortunate since i feel like medicine has the potential to be such a creative space and i think a lot of covet actually has brought out some of that creativity and innovation but at the time really craving uh this sort of communal uh catharsis so fast forward four years and we were able to really build on that momentum and um pre-cove it in january we're fortunate enough to sell out the yerba buena center for the arts in san francisco it's a 700-seat theater we filled it up and had physicians and other healthcare workers telling stories about themselves on stage around that time we were also doing a podcast spin-off and so the way that the podcast was working at the time was the first half of the podcast was a live story clip from one of our live shows and then it would be followed by a conversation between me and the storyteller so this is what we were doing we were actually in our third season of this podcast uh when kovid19 hit in march and we just dropped everything and our team looked around at ourselves and we were like wow our organization has never made more sense than it does right now because we had really been spending four years taking care of the hearts and souls of physicians and we saw that we were facing um what in many ways is one of the biggest plot twists uh in medical history and really wanted to make ourselves available to serve our community and to continue to be a space and an outlet for self-expression and for healing and for community and for well-being so what do we do uh so what we ended up doing is putting out a call for audio diaries and this was different from what we had been doing before because previously we were asking um healthcare workers to come into our team and craft like a perfect 10 minute story with open opening scene and an ark and stakes and conflict but this this was like come home from work turn off the lights talk into your phone don't prepare don't write don't think just tell us what's happening tell us what's on your mind and so we put out this call and within about 40 or within about uh 24 hours we had 50 people sign up and then over the course of the next few weeks we actually ended up having over 200 people sign up to participate in this project people from all across the united states a lot of physicians but also some nurses we had a chaplain we had a dme uh medical equipment truck driver sign up to participate all sorts of voices and we effectively um received i want to say uh 700 audio clips between the months of march and may and so our team would sit and just listen to these audio clips listen to what was going on on the ground um and started to produce these episodes podcast episodes um and we produced them in the style of saturday night live where basically every tuesday we would release an episode and then the clock would reset and we would look at the material that had come in the week before and try to pull out themes that were coming up try to um highlight contradictions that were coming up and really just keep our finger on the pulse of what was happening on the ground and pump out these episodes every week and it was great because the audio diarists who were contributing could hear their own voices on the show in real time and could hear the voices of strangers across the country who were going through this experience alongside them and what was also interesting about it is that each audio clip itself isn't necessarily a full story there are these moments these slices of life and when you weave them together into a tapestry this larger story starts to emerge of what is it to be a healthcare worker you know during coven 19. so this is what we did and the question comes up why is this important why is storytelling so important during a pandemic and i think in medicine a lot of us tend to focus on the science and the data and that is hugely important i think um even some of the other speakers today are showing us the importance of epidemiology and tracking and evidence and and all of that but i also think it's really important for us as a medical profession to just take a breath and just locate ourselves in the chaos of what is happening right now and ask ourselves how are we moving through this moment what is coming up for us where are we sad where are we angry where are we frustrated or lonely where are the moments where we're finding joy where we're finding hope where we have moments of triumph where are the moments of complexity and contradiction um for example we had a diarist send in a clip from indiana and his wife was undergoing chemo for cancer and he was a pulmonary critical care physician and um wasn't going to go in to take care of covet patients because he wanted to protect his wife who was immunosuppressed and he was really conflicted about it i mean on the one hand he was relieved and he was glad that he didn't have to go in and put himself exposed to this virus on the other hand he was having like fomo and you know kind of wanted to like jump in and lend a hand and and it was all of those feelings layered on top of themselves simultaneously and i think um what's really been great about this project is we've been able to give voice to that emotional complexity and give people the opportunity to really metabolize this experience and create meaning out of this experience storytelling is a very powerful tool for making meaning and also to do that communally to do that as part of a larger group particularly a group of other health care workers who kind of get it and understand what it is to be going through this um is really powerful so just briefly i just wanted to touch on some common themes that came up as we were listening to this audio since people ask a lot about that early on there was a lot that we were hearing about fear about uncertainty about bracing for this tidal wave there was a lot coming in about leadership and what it means to be an effective leader during this time how do we communicate with each other about new policies that are ever shifting um who were the people who felt they were being led well who were the people who did not feel like they were being led well there was a lot about loneliness and social isolation the deep need that we have to touch each other and to connect to each other face to face um there was a lot that came up around the concept of sacrifice around the identity of being a physician and the rhetoric that was being used in the mass media about doctors and nurses all of these military metaphors that are being tossed around like going to battle or being drafted um so that came up a lot um questions of guilt questions of how do we assign value to things in health care um questions of health equity as we saw how this pandemic ripped through our most vulnerable patient populations in this nation and then toward the end questions of where do we go from here how do we use this historical moment as a fulcrum to really pivot and and rewrite the future and give us a different american health care one that is more equitable one that is more sustainable one that is more healthy um so in terms of where we're going from here um we're gearing up so we did the 10 podcast episodes um which you can listen to it's an audio documentary series on our website uh thenocturnist.com and then we have an interactive story map where you can listen to the stories by geographic location and we're currently in conversations with a major cultural institution which i can't name at this moment but i'm talking about enshrining this audio library as a historical document to be preserved which can be accessed by historians in 100 years which i also think will be really important and we're going to continue to collect audio so if you or anyone you know is interested in contributing please feel free to reach out we're gonna produce a part two of this series um and so maybe i'll just pause there i think one of the best ways to really get a flavor of what we're doing is to listen to an audio clip and so i've selected this clip it's just under three minutes it's short um thank you for transitioning to the slide this is our beautiful art that was done for the project by illustrator lindsey mound and i might just ask that you take a breath close your eyes listen to the story this is a clip that was sent in from an internal medicine physician named kat from michigan a couple of months ago and i think you'll see hearing the clip uh just how much she brings us into her world into the hospital and so let's roll the clip today is april 26th it's a sunday five o'clock and yeah i'm in the hospital even though i'm supposed to be off but i don't care today because i am i'm walking through the basement and i'm looking at a unit of convalescent plasma like i'm holding it in my hand and walking it to the icu right this minute because my hospital is lucky enough to be one of the sites for research that we've got something in our arsenal that we think really works and it's really cool i've watched everybody perk up at each stage of this process of hey we got registered as a site hey we consented and enrolled our first candidate but now that now that it's here now that i'm looking at it it feels [Music] so much better um when i go in to consent another person in another room while we're waiting on it to thaw i feel hope we feel energized and so i think that's what we all need right now because the hope and the energy is is losing it but you know it's those little things the patient that we discharged from the rehab unit to go back to his family who was up and walking and gonna be like his normal self that that was a win too that was a good one so yeah i'm really excited to walk through the icu doors and go hand this off to the nurse who's going to hang it for our really sick prone ventilated patient who is happens to be one of my primary care patients through sheer dumb luck today's a good day i don't mind being at the hospital today just left the hospital and the sun is out it's gorgeous outside but the best thing the very best thing is the refrigerated trucks are gone none of us wanted to talk about why they were there in the first place and we're still gonna lose patience there's no question there but things are starting to feel more like we can we can handle the bad stuff and there's more good stuff um so that gives you a taste of what what we've been collecting the type of audio we've been collecting if you're interested in learning more you can visit our website uh the nocturnist.com and thank you for your time and attention and uh i'll just turn it over now to dr ashley mcmullen who will talk about our other serious black voices in healthcare great thank you great all right thank you emily um so yeah that the next series of the nocturnes has been black voices in healthcare and really the idea for this project um came out of the or in the wake of the george floyd murder which was at that time just the latest in a series of examples of anti-black racism in our society and while this isn't new it definitely hits uh differently in the context of a pandemic that is certainly disproportionately impacting communities of color especially african american communities and so recognizing that you know in this moment specifically um in healthcare what we need is not only a um a greater awareness of this issues of these issues um what we need is empathy and uh certainly empathy across differences and stories are just one avenue to do that and so that is kind of the motivation behind launching this series and so i actually um would love to just go ahead and transition into a clip um from one of our episodes again similar to the last one's going to be just under three minutes and then i'll jump back on with a couple comments after that i still remember the day i met her on rounds i'd taken of our service on the inpatient hiv service and she had been in the hospital about 30 days young girl advanced hiv aids battling a couple of opportunistic infections and she was starting to finally get better she was being wind of oxygen and was starting to regain her appetite which started on anti-trivial medicines in the hospital i remember meeting her and she's probably 24 25 slightly older than my kids and all i could remember was how little she looked and how much hair she had her hair was big it was huge but it was matted and she's been in the hospital she'd been in the icu and through all of that the transfers back and forth no one looked at her hair i've spent many years in the hospital i'm used to bringing in little hair ties and getting out the little rubber bands on my wrist to give to a patient because i know black women our hair is important our hair is part of what defines us and when people are in the hospital a lot of times that just falls by the wayside the little bowls at the bedside with the one shaving stick and little tiny comb doesn't cut it it never has never will and there's nothing like having your hair done to make you feel like you're getting better but this one girl well young lady was just finally getting better and i told myself i would braid her hair i'd never done that for a patient but there was something about her she had this fight in her eyes and she was going to get better and i know that just feeling better about how she looks would help so i asked her how she liked her hair and she said oh she always got her hair done twice braids different things so saturday morning we got done around it's pretty early we didn't have a lot of admits we were pre-call and i just went into her room and i said hey do you want me to braid your hair she was surprised she said doctor you're going to i said sure said i've been braiding my sister's hair for a long time i have three younger sisters i have two daughters both my daughters used to fall asleep with me braiding their hair i like to tell myself that my hands are are soft i sat by the bedside and i braided her hair into eight cornrows to the back she looked fabulous [Music] awesome so what you guys um heard in addition to that clip or what you saw or what you're saying now sorry is the um beautiful artwork we have for our illustrator for this series um which is a piece by ashley florial so in that clip it's actually one of my favorite stories of the series but you hear from a black physician who's caring for a black patient who's been ill for quite some time and the idea being that she's able to establish this connection um that kind of sees the patient beyond just a series of illnesses but really allows her to touch on that piece of her humanity and recognizing that hair is a big part of black identity especially for for black women and so um being able to uh do her hair played a role in that patient's healing and again just elevating the humanity that can sometimes be absent in medicine and so really the the hope for the series is that it allows listeners just a greater proximity to the black experience through the lens of black healthcare workers and highlighting not just the the pains and difficulties that come with um being black in our society but also that the joys and the strengths and and the triumphs and also just the complex humanity that really connects us across differences um and specifically as people who work in healthcare and are working during this uh this unique time in the context of covet 19. and so again hoping that by listening by having this proximity by gaining under better understanding and better empathy it can start to lower some of the barriers to having the difficult but necessary conversations that we need for for lasting change in this moment and going forward um so with that i want to you know turn it back over to you bob and hopefully have some time for questions maybe your family can come take down the slide and the family can come back on and it was time for just a question or two that thank you both it's incredibly powerful and the whole series has been has been just great um you know i remember when emily started this or we had a conversation about this and on a drive from one of the hospitals to the other um you had some sort of dreams about what it would become can you talk about sort of whether you're reaching them and what if three to five years from now this even exceeded uh where it is now what would that look like for you and maybe for both of you actually sure i would just love for the nocturnist to be the place to go to access really compelling provocative stories about what it means to be a healthcare worker um in the united states i almost dream of it being like this american life or medicine specifically and i think what's really unique about this project is it's by healthcare for healthcare um when i went into this project i wasn't a journalist um and i was an md and it was really born out of my own hunger to create the space for mds and then later expanded to rns and other healthcare workers and i find that when people share audio with me the fact that um i and a lot of the others on the team are doctors like they're sort of this different way of talking to each other um i just noticed that when physicians speak to journalists or the or the lay press there's this like filter there but when you're talking to another doctor you kind of get each other as i said um and you can talk in a certain language and i think that's one thing that makes our project really special is the way that we've been able to build that trust and camaraderie um and really not be afraid to explore our own vulnerability and i think to do that with another physician organization as a guide would be really powerful great great ashley what's what's your dreams for this yeah well i guess my first stream is that we can do live shows at some point again and that will be um that will be exciting i think you know as far as my hope um especially with the series is that it's just one um uh one catalyst to integrate more narrative into how we practice both in the way that we how we see our patients and also the narratives that we tell among our colleagues to again kind of get us out of these professional silos and recognize that there's so much humanity and so much depth in the storytelling experience that happens in medicine and i think that just makes us better at what we do well thank you both it's really uh powerful and it's just throughout this entire thing it is uh it's increasingly clear that the number of lenses that we have to use to look at this and get it right is uh is is extraordinarily large and if you're just looking at it through the quote scientific lens you're missing a ton and just you know the power of of what you've shown us today is uh is it really demonstrates that quite clearly and i hope people will go to the site and and listen and contribute and uh and also uh i hope we have live shows sooner rather than later so thank you both for being here let me thank all the speakers again a reminder that next week for ucsf folks our grand rounds will be replaced by a presentation at the same time by the campus looking at the future of parnassus we'll take a couple weeks off after that including the production team as you see here they get a little bit of break and we'll be back on thursday september 10th with another in the series we'll post this tonight on youtube at about 7 30 pacific and uh we'll have a good copy of the uh of the first video so thank you all for joining us stay safe and uh insane and uh hopefully we're moving closer to the end as we go forward we'll see in a few weeks thanks so much

Channel: UCSF School of Medicine

Views: 81,233

Keywords: ucsf med school, ucsf medical school, university of california san francisco, med ed, ucsf medical student, uc san francisco school of medicine, doctors, physicians, ucsf, medical education channel

Id: Ew2MEF4XX8w

Length: 89min 33sec (5373 seconds)

Published: Thu Aug 13 2020