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[00:00:05] Samantha: Hi. I’m Samantha. Welcome to The Layman’s Doctor podcast Where We’re Bringing Medicine Home. If you’re having some issue with the audio, it’s because we’re recording this online. We’re practicing social distancing. We’re recording this on the 22nd of March. And you know that COVID-19 is here in Jamaica. Today, we’ll be talking about COVID-19, all about it. Everything about it. And I have a guest with me here, Dr. Yohann White. I’m going to leave him to introduce himself and tell us all about him. And he’s been doing a lot of stuff on advocacy around COVID-19 as well.
[00:00:47] Yohann: Great. Thank you, Samantha. Good to be here. And just a little bit about me. I’m from the medical class of 2007, UWI, Mona, University of the West Indies, Mona. When I finished medical school, nearly immediately after, I went to pursue a Doctor of Philosophy degree, focusing on disorders of the immune system, specifically chronic viral infections in a cohort of patients in Japan that I followed up for a few years. And after that, I left to do a post-PhD or what we call a postdoc, working with the US military, working on vaccines for diseases that we don’t yet have safe and effective vaccines for. And then since 2017, I’ve been in Jamaica, working around infectious diseases, vaccines, and conditions that affect our immune system or our body’s defenses against germs.
[00:01:50] Samantha: Okay. All I’m hearing is that you’re the perfect person right now for me to talk about COVID-19 with. Wow. And that’s the thing. I didn’t even know a lot of these things that you did before. But I just knew that once COVID-19 came out, I needed to have you on here, so we can have a discussion about it. I see you in your own space on Twitter, which is where I follow you most, and on WhatsApp stories as well, just talking about this virus. So let’s just go really basic here. What is COVID-19?
[00:02:34] Yohann: Great. So COVID-19 refers to coronavirus disease 2019. It is actually the disease that results from infection with the virus, which is called SARS coronavirus 2 or severe acute respiratory syndrome coronavirus 2, which is related to SARS that we saw in 2003. So SARS-CoV-2 is the germ or the virus, and the disease is coronavirus disease 2019, COVID-19.
[00:03:05] Samantha: Okay. And this is– they had changed the name recently. It was novel coronavirus before, and now it’s changed to that.
[00:03:12] Yohann: Right. Right. So it just points to the fact that this is a new disease, a new germ, and very little was known about this virus. And information continues to be produced in high volumes on a daily basis. And sometimes the things that we understood initially have to be updated and we– there are still many questions that remain about this condition. It is a novel coronavirus. So a new virus has emerged from a particular environment in which wildlife was exposed– humans were exposed to wildlife that carried different types of viruses. And there was the opportunity for a sort of super virus to emerge out of that setting in China. And it jumped into humans, including, for example, the vendors who were selling these wildlife in China and the vendors’ families and the vendors’ customers.
Subsequently, healthcare workers, patients who came into the hospitals there for different reasons also started getting ill, and family members of those patients, and family members of healthcare workers, and subsequently, the whole world is now facing this public health challenge. It is able to spread as fast as it does because of features of the virus itself, number one. But two, and perhaps more importantly, we have no immunity or no protection against this virus because our immune systems have never encountered this virus before. And so everyone is susceptible or vulnerable to infection with this virus.
[00:05:01] Samantha: So I remember a conversation that I had with you a couple weeks aback. I had a– still up in the air whether it was a flu or cold. More than likely it was a cold. I didn’t have a fever. I mean, it was just some sniffles that was making me really uncomfortable. And I remember us very specifically having a conversation between the influenza and the coronavirus, which is what usually causes the common cold. It’s usually a milder infection that we can tend to get over. But we’re seeing now that with COVID-19 that the symptom, it can– we’re seeing that it’s more reflective of when SARS was around and when MERS was around. And it’s no longer, in quotes, “the cold”.
[00:06:00] Yohann: Right. Coronaviruses have, in fact, as a group or as a family of viruses, been with us for a very long time and they account for what we know as a common cold. So the sniffles, the runny nose, a little funny feeling in your throat, maybe a little cough. That, we’re used to. But this particular virus, this novel coronavirus 2019, SARS-CoV-2 is different because it has features that allows it to spread easily, one. Two, it is associated with higher, relatively higher, mortality or deaths from infection. And a part of it is that this virus can directly damage the lung tissue. So our breathing passage and our lungs, which are like these big sponges in our chest that absorb oxygen so that they can pass it around to our brain, to our bodies, our heart. But the virus, SARS-CoV-2, can directly damage that spongy tissue. In addition to that, it also causes our body to respond in a very aggressive way because our immune system is trying to clear this virus. But sometimes our immune system can be excessive or it results in sort of bystander damage to the rest of the lung tissue and to our bodies.
Many of the symptoms of respiratory viruses, in general, including the common cold or flu or influenza or COVID-19, may be similar. There’s a lot of overlap. But there are certain things that we look out for to try to determine which one it’s most likely to be. Of course, one of them is exposure. So if you’ve been travelling, and if you’ve been in Wuhan, China, or any area where there’s active transmission of SARS-CoV-2 now, and any symptoms whatsoever, that is a red flag for us that you may have COVID-19. But apart from that, the common cold usually gives you mild symptoms: a runny nose, maybe a little funny feeling in your throat, maybe a slight fever for some people, maybe a mild cough. But your energy level is intact, your appetite is intact, and you’re able to go about your normal business. You’re able to go to work. You may have to blow your nose often and it’s a little inconvenient, but you can concentrate and you can get your work done.
As opposed to flu, which has very similar symptoms to COVID-19, or in other words, COVID-19 has very similar symptoms to the flu, you get more systemic symptoms. So you feel ill. So you may have a headache. You may have a sore throat with either the flu or COVID-19. You can have muscle pain, joint pains. You also feel sick, tired, like you want to be in bed. And this can be seen in influenza; this can be seen in COVID-19, loss of appetite. And depending on how much virus you have in your body, then the symptoms can be more severe. Some persons also have symptoms outside of the chest. So that includes, for example, diarrhea, and some persons, even vomiting or feeling as if they want to vomit.
But with COVID-19 in particular, the most common thing that will happen in COVID-19 is that most people may have no symptoms at all. Or they may have mild symptoms that look like a common cold. But there are some persons, perhaps one in every five persons or two out of every five people, will have severe disease because they develop shortness of breath and require some assistance in a supervised setting like a hospital.
[00:09:58] Samantha: So I know that we have a case definition: fever, cough, shortness of breath or difficulty breathing. And then these symptoms coming arounds 2 to 14 days after you’ve had some exposure, whether from travelling or being around someone who has travelled.
[00:10:18] Yohann: The thing with all these symptoms is that nobody’s going to have all of them. Everybody will have their own constellation of signs and symptoms. Of course, sneezing can be one of them. Shortness of breath can be one of them, sore throat. But we may say, for example, a sore throat is more common with the flu and it can be seen in COVID-19, but nothing is absolute. It can be seen in COVID-19. You can see diarrhea. One in 10 persons who come to hospital with severe disease have diarrhea, 1 in 10. And it’s usually associated with more severe disease because of the risk of dehydration and other complications. So there’s no absolute combination of symptoms. [inaudible] will have fever, some people won’t have fever. Some people will sneeze and some won’t sneeze because even if it’s not a symptom and we have other reasons to sneeze, if you do have COVID-19, sneezing is one of the ways in which the droplets are spread. So even if you sneeze for another reason, and you have COVID, you could [spread it?]. You will spread the droplets.
[00:11:26] Samantha: I want you to just bring up the date again because, again, today is March the 22nd. Every time that we talk about this new virus and the disease that it causes, the information seems to be changing all the time because we’re doing this– all of this is in real time now. So you brought up a point that a lot of persons may not even have any symptoms, and the conversation has been going towards social distancing, handwashing, but also testing, testing, testing, testing because we’re now learning that persons can be, I believe, asymptomatic, but still pass it on, or just have milder symptoms and still be passing on the virus.
[00:12:11] Yohann: Right. Every day we learn more about this condition and the world is under a lot of pressure to put public health measures in place to try to stem the spread of this disease and to mitigate the impact that it will have on our health system. Now, depending on where in your epidemic you are as a country or a society, then the strategies that you implement may have to change. So, for example, if you want to prevent introduction of infections from overseas into your population, then aggressive monitoring of your ports of entry would be critical. If you are having local spread, so from imported cases, but now to contacts of imported cases, and other contacts of contacts of imported case and [inaudible] or infections or cases that you can’t identify any specific exposure, like a short contact with somebody who was known to have COVID-19 or any travel history, then that suggests local spread or community spread.
As those numbers go up, your strategy has to adapt to what’s happening. And so social distancing– the purpose of that is to prevent people from being in group settings or where the opportunity’s there for spreading this infection. So you close schools, you advise against, or you put in measures to decrease social gatherings, and you encourage persons to stay home. But that is not enough or may not be enough when the scenario starts to get worse.
So as you rightfully pointed out, initially, it was believed from the data coming out of other countries that most of the spread was attributable to persons with symptoms. But we now know that it is true that persons with symptoms are more likely to have more virus. And if you have more virus, you’re more likely to spread. And they have more virus because there’s something compromised with their immune system. Therefore, they don’t have a strong response to the virus, or an impaired ability to clear the virus. And so they carry more virus and they’re more sick for a longer period of time and they therefore shed more virus. So it is true that persons with symptoms tend to be more infectious or more easily pass on infection.
However, we do know that a significant number of persons may not display any symptoms, or it may be that they’re in the phase where they’re incubating or not yet showing symptoms, but they’re carrying an infection. If those persons are allowed to roam about or to be in contact with other persons, then that facilitates spread. And so at a particular part of your epidemic or in the early stage of your epidemic, finding these positive individuals will be important. And the main strategy that we’ve observed here is for public health officials to basically chase after the contacts of known cases of COVID-19 and to interview them and to see how long they spend time together, what they did together, they lived in the same house. And then to sort of isolate those persons from the community, whether or not they have symptoms.
But so far, testing, the purpose of which is to identify people with this virus is focused on persons with symptoms. And therefore, there is the possibility that some persons without symptoms or with mild symptoms may be missed from this approach. And therefore, there’s an opportunity for those persons to spread infection to others.
[00:16:23] Samantha: Okay. So I feel like we’re watching– using Jamaica as an example, and you talked about the different steps that you take based on where you are in this pandemic, we saw where Jamaica had its first imported case. Eventually, we have moved to the point where our borders are now closed off, except for, I think, cargo. We’ve also seen where we’re– because we’re having locals spread now, that schools are closed. They’ve been closed for a while now. More and more businesses are either asking you to work from home or they’re just completely closed themselves.
And now, we’re seeing a lot of information about prevention out there, and social distancing, yes, staying at home, not going out, staying– I also interpret it as even if you’re in the house with somebody, also want to try and stay some distance from them as well. But we’re basically trying to prevent this from getting any worse than it is now. So we’re having communities quarantined. We’re having persons isolated. And I think that– I feel as though, eventually, we will start to, maybe, lower our threshold for testing. And even when persons may not fully meet the criteria of the case definition, that we will also start doing some testing.
[00:18:08] Yohann: Tests, there’s an availability issue. And a part of it is a slow recognition of how serious this pandemic is by countries where the manufacturers are located. So by the time they got the memo, they’ve had to now be scrambling to ramp up their production to meet their own needs there. As opposed to, if they’d heeded much earlier and put certain things in place, then there would have been enough. But there’s a point in your epidemic when you have more testing capacity than how your cases are emerging. But it’s really a balancing act and a timing issue in terms of when to deploy that testing capacity to find the positives and to try to interrupt transmission. Because there will come a point, as we’ve observed for other countries, where the cases emerge so quickly that you’re just overwhelmed, and testing means nothing at that point, really. And you won’t be able to test and isolate because it’s a wildfire by that point.
So it’s really a timing issue, and then it’s really following the science and observing what worked in societies where it worked. And also, to see the consequences of not doing certain things by a certain time. So we still have a window of opportunity where, I hope, we can get that right because to think otherwise is just really, really concerning. I wish we were doing the South Korea strategy, which is to test and find the cases and isolate them before you– the countries that have seen their health systems get ravaged, really, are the ones who did not pay attention to South Korea’s strategy. That’s where you really want to pour in your resources: prevention. But it’s very easy to miss that boat if we don’t pay attention to where we are in the pandemic. So it’s really just– there’s so much uncertainty. And it’s an enormous challenge that lies ahead. It’s really, really a different time.
[00:20:48] Samantha: But—
[0:20:50] Yohann: Right. Just to interject here to say that, indeed, Jamaica has taken very decisive steps, and there has been strong leadership from our public health officials, and there has been a whole-of-government approach. In fact, Jamaica has been more decisive in implementing these social distancing or physical distancing measures well ahead of some countries who delayed those activities and are now seeing the consequences of that delay. However, the purpose of doing that is to try to slow the spread in the community, such that you don’t end up having so many cases and so many infections that everybody turns up to your health system on Monday morning or on one day or within a short period of time, because the health system does not have the capacity to deal with that many cases. And so by distancing people from each other, the spread is slowed in the community, and the cases emerge at a slower rate. And so the cases are spread over a longer period of time. And the hope is that if they come in, or the cases are rising at a slower rate, then your health system, maybe, can cope with those cases. But it will be over a longer period of time.
However, even with that measure, or those measures, and decreasing the number of infections, the numbers that result can still be overwhelming for our health system, especially in a developing country context because we need only look at very wealthy countries, how their health systems have, in fact, essentially crumbled under the number of cases that they’ve seen. So, in a way, it buys us time to be able to do something else. And a part of that, in my opinion and from my observation of the science and the data that’s coming out of other countries, for example, South Korea, Thailand, Taiwan, etc., identifying the positive cases, or persons with infection who may have mild symptoms or no symptoms is important, so that they can be isolated to interrupt the spread of that infection.
[00:23:33] Samantha: Okay. You brought up– wow, you brought up a lot of stuff. So I’ve seen a lot about flattening the curve. So this, what we’re talking about, and I know that– in terms of being decisive, I know that the WHO basically said big ups to Jamaica for the action that we’re taking, and you have to appreciate the Minister of Health and the government for what they’re doing and what they’re trying to do in order to try and prevent this disease from getting worse. But when you were talking about all the measures that we’re taking in an effort to slow down, does that have anything to do with flatten the curve? I’ve been seeing it a lot.
[00:24:22] Yohann: Yes. Yes. That is the term assigned to that strategy, which is to instead of having a peak in your cases in a very short period of time, you spread out those cases. So you flatten that peak, you flatten that curve, to make the cases– essentially to slow the pace at which cases develop and present at your health facilities. But scientists have raised the concern that, how long can one have those measures in place? Is it really 14 days? Is that adequate? Or is it going to be a month or two months or three months? So it’s really– there’s some uncertainty about how long countries will need to implement such measures. But for sure, a part of it is also buying time to put other measures in place, such as beefing up your health systems. So getting ventilators, personal protective equipment for your healthcare workers, getting testing capacity in place, identifying quarantine and isolation and supplementary facilities to deal with the cases. It’s really to buy time.
But countries face an immense challenge with what is ahead. But we also know from countries that have not only flattened their peak, but actually cut their cases very rapidly and seen a decline in a very short period of time, such as South Korea, that was associated with expanded testing at a very early stage in their epidemic before the cases go beyond your country’s testing capacity because at some point, the surge will be so much that it will vaporize your resources in terms of laboratory support for testing, etc. So that sort of a strategy is appropriate for just about where we are in our epidemic right now because there may actually never be this window of opportunity again to find those positive cases that may be responsible for spread in the community. And, yes, there’s an argument that persons with symptoms do spread infection more easily, but persons without symptoms are maybe about 50% as likely to pass on infection. And that’s a lot because persons without symptoms or with mild symptoms significantly outnumber the cases with severe symptoms. And so by virtue of that larger number, they’re responsible for driving the pandemic.
[00:27:33] Samantha: So what we’re seeing now, what we’re doing is with all these measures that we’re taking, it’s all in an effort to find persons who test positive for the virus, and then having them removed from the community or from– or having them isolated so that they can decrease how much– I don’t want to say contact, but how much they’re able to spread the virus.
[00:28:04] Yohann: Right, in countries that are doing that, and we in Jamaica are not yet doing that. We’re testing only persons with symptoms.
[00:28:13] Samantha: Oh. So we’re not there– so it’s kind of sounds like we’re doing half of it. So it sounds like we’re doing the, okay, stay at home. Stay at home Don’t go to school. But we haven’t yet started the testing part as yet.
[00:28:27] Yohann: Right, from my observation. But the measures that are being taken are updated regularly, and those of us in the public health community and scientists would hope that at some point we are not only testing persons with symptoms, but we are testing to identify persons without symptoms who may be responsible for spread. It is our hope that that strategy will be adjusted and implemented. Currently, as you mentioned earlier, there are specific criteria that have to be met for testing to be done. And that’s for surveillance purposes. So, in a way, those who come to your health facility, usually those with more severe disease, will be tested if they meet certain criteria, such as symptoms plus travel history in the past 14 days, or contact with a person confirmed to have had COVID-19. Those are the persons who are prioritized for testing at this point.
[00:29:34] Samantha: So what I want to know is if they start just testing persons who have milder symptoms or who are asymptomatic, is it kind of a test-all approach, or will they also have criteria for that? Because then, we can’t– we have to bring up our resources. And if we’re actually physically, in real life, able to do this to take on that approach.
[0:30:01] Yohann: Right. That’s an excellent question. So mass testing is not something that I’ve heard being advocated, which is different from strategic testing. So, for example, rather than just contact tracing, or looking for contacts of persons known to have COVID-19, and then interviewing them, and then only testing those that have symptoms, maybe a more strategic approach would be testing all the contacts of these persons known to have COVID-19 because, even if they don’t have symptoms now, they may be incubating, may have been exposed, and possibly could develop symptoms later. And if your trigger for testing is developing symptoms, then they may be in the community with infection, unknowingly. And persons may become infected from exposure to them.
So that is more strategic testing, as well as testing healthcare workers who are on the frontline and may have frequent exposure with cases of COVID-19 because if the status of the healthcare worker is not known, then they could become a focus of spread to other patients, to other healthcare workers. So that’s what we mean by more strategic testing, which is somewhere between mass testing and somewhere between just testing people with symptoms. And there is a stage in your epidemic locally where that will be useful. And if one waits too long, then there’ll be a point when it is no longer practical to do that.
[00:31:52] Samantha: Okay. So let’s shift to healthcare workers for a moment. I made a tweet earlier this week about– just basically saying, “Close your eyes. Imagine if you tested positive for COVID-19, or rather SARS-CoV–” what’s it, SARS-CoV-2?
[00:32:16] Yohann: Yeah, SARS-CoV-2, coronavirus 2.
[00:32:19] Samantha: Yeah. So imagine that you tested positive for that. And then just think about all the persons who would have to get tested or be quarantined or be isolated. And I basically said, “Imagine a healthcare worker,” right, because– and I tweeted it simply because I was imagining it. If I come in contact with so many people just by being at work, not just patients, but also other healthcare personnel, and that could really mean that I could put a lot of persons out and it could decrease our ability to treat and respond to this crisis. So I agree that persons who are on the frontlines, we need to know their status. And then this is such a timely conversation because just today, as I said, today is March 22nd, that’s Sunday, March 22nd, when an article came out that has since been retracted, about healthcare workers testing positive, or persons being on the frontline. And when we see this article, it kind of, for me and for my work group when we had the conversation, it brings back the reality that we are at risk. But because we’re at such a great risk, us testing positive can be catastrophic for the response. So with that, how do we try to keep the numbers down or keep them to remain at zero? And how do we continue to protect healthcare workers?
[00:34:14] Yohann: I don’t know if it would be catastrophic to know one’s status if, in fact, you have COVID-19 or you’re infected with SARS-CoV-2, because it would provide the opportunity to do an intervention, which is to isolate or quarantine that individual, and [crosstalk] with spread.
[00:34:31] Samantha: So what I meant by– so, for me, what would have been catastrophic is not knowing. So we would just be passing it on, passing it on, passing it on.
[00:34:41] Yohann: Right, and creating more cases. The concern is that if persons are positive and then you have to pull them from the frontline, it may have an impact on our ability to deliver care. But I think the former argument is a stronger argument, that you don’t want to have healthcare workers who may have this infection potentially passing it on to others, is a real concern. There’s so much information coming out about this condition and how it’s spread and what interventions may work and over 100, 160-plus countries have seen cases before Jamaica. And so there’s a lot of opportunity to learn what has worked and what has not worked, and to see how we can adapt our response as we go along. Protecting healthcare workers is going to be critical. Equipping them with the appropriate protective gear and having proper infection control systems in place and training in place are going to be critical.
Persons with mild symptoms or symptoms that are moderate who can be managed at home, it is better for them to stay home. But understand when it is important to pick up the phone and call a physician or a hospital or the Ministry of Health if you’re not improving. So that public education and sensitization will be important because the health system will not be able to accommodate every symptomatic person. The health system is really reserved for persons with severe disease or having difficulty breathing, significant shortness of breath or having a lot of symptoms, including chest and, perhaps, gastrointestinal symptoms and other symptoms that puts them at risk for dehydration and other complications. But also individuals who we’ve observed have not coped well with this infection, which includes mostly the elderly. So person’s over 80, persons over 70, persons over 60, are more prone, especially if they have other underlying medical conditions, such as high blood pressure or sugar or diabetes or heart failure, kidney disease, or any chronic medical condition.
But we have also seen cases of younger persons, 20s, 30s, who have also not coped well with disease. So the deaths that have been observed, even though they’re fewer than maybe 1 in 100, or even far fewer than that, have been skewed towards the elderly, yes, but there have been, unfortunately, fatal cases in younger age groups. For sure, chronic medical conditions seem to put persons at an even greater risk of not coping well with this condition. But most people do recover, and most people bounce right back. And that will be the situation going forward. But we do have enough people who fall within those high-risk categories to still overwhelm our health system.
[00:38:11] Samantha: Definitely. I like the part about stratifying patients and treating some of them at home because for years and years, we’ve always been talking about that: our health facilities aren’t growing with our health population. And it very well could easily overwhelm a lot of the health facilities. So knowing that we have in place or that it is a possibility that these persons can be treated at home, and knowing when to escalate. So I know that other countries, especially Wuhan, China, they have put out– I don’t know if I should call them protocols, but kind of said, from their experience, things that they did well and things that they didn’t do well. I know a lot of persons have been talking against not using protective equipment when going to treat because they had– well, there are instances where sometimes you decide to treat a patient, even without proper protective gear, of your own. And they’ve spoken– I don’t want to say “they” to mean specifically Wuhan, China, because I’m not 100% sure of where I was reading it from, or if it was– I know they had used that example with other outbreaks where this is something that we don’t want to do. We want to always ensure that we are properly and appropriately protected.
Other countries have used– have been using medical students. Recently, our own government has asked medical students to volunteer. Somebody asked me the question and what I said to them was, “You know, if they’re going to ask them, it has to be a case where they’re protected, whether through personal protective equipment, or whatever work they’re doing does not put them at risk.” And I was just saying it’s a great time for them to basically use their platform to spread correct information about the virus. So a lot of persons are up in the air about whether or not medical students should be involved. I don’t know if you want to give your opinion on it, what you think.
[00:40:46] Yohann: Well, the response will require volunteers from all sectors, all walks of life, including medical students because we have a fairly good educational system, but it will be important manpower. There are specific tasks that could be efficiently executed by medical students under supervision or with clear communication and proper training. But it may be a better pool to call upon than, say, retired nurses–
[0:41:28] Samantha: Agreed.
[00:41:29] Yohann: –because I did see that announcement– not that retired nurses can’t be helpful, but they fall in the demographic that is at high risk for not doing well with this condition. But there are things that can be done in the response that are not frontline work. So educational activities, communication activities, manning the phones, that sort of administrative support can be useful. But I’ve talked to a few retired persons and they– I’ve met persons who were not interested, but I’ve also heard of stories where persons have volunteered despite having retired. So there is a place for everyone in this response. There is certainly a place for every person, in terms of our personal practices, that could reduce our risk of infection, which is avoiding large crowds, washing our hands frequently, cough and sneeze etiquette, staying away from people who exhibit flu-like symptoms, refraining from travel. Those steps are really important in reducing the spread in the community. And so every single person does, in fact, have a role to play in this response.
[00:42:59] Samantha: I agree. And one thing I would say, though, is for persons who come on to volunteer, I don’t have– I can’t tell somebody what to do or– for me, I can’t tell them if they should or shouldn’t. [inaudible] is just for the persons who have spoken to me about it, who have asked me about it, I’ve always just said I think it has to be completely up to them whether they choose to volunteer or not.
[00:43:28] Yohann: And as you alluded to, we really do have a responsibility to ensure that persons who volunteer or who are employed in this response are adequately protected. And protection means providing the appropriate protective gear, but also the appropriate training in terms of how to conduct themselves and safety training and all of that, will also be critical.
[00:43:56] Samantha: Definitely in terms of that because I think we think that just having the PPEs is enough, that’s the personal protective equipment. But I was in a session just last week and we were learning how to don and doff the equipment. And it was one of– I know the different types of masks. I know the different types of gowns and so on. But this was the first time I was doing it. And it’s very easy to mess up, especially if you’re not doing it consistently. So I just remember just there because I was the example. I volunteered to be the example and putting on the masks, for example, just doing that properly, putting on the protective eyewear, and the fact that when you’re taking off, you have to sanitize in between. There are a lot of small steps that are so easy to mess up, even how you just take off your gloves. And unless we have– I’m not confident. I will say that I’m not confident, after just one session, that I know how to do it properly. It’s something that I would have to have continuous training and refreshing on.
But luckily, when you are doing that, you do have a buddy with you who kind of ensures that it is done properly. And if there is, at any point, any point of contamination, that you’re able to kind of recover from that. But it’s not enough just to have it. You have to have the training on top of it as well. And I think I’m known to be someone who talks a lot about protecting healthcare workers. And healthcare workers I think– and now at this time, we have to ensure that we speak up and we’re comfortable with saying, “I’m not comfortable,” or, “I don’t think I’m adequately trained,” or, “I need my mask. I need my gloves,” whatever, “I need my protective equipment,” before going on to do something that might potentially put you at risk.
[00:46:32] Yohann: Indeed, indeed. And preparedness for pandemics is something that really ought to be built in our medical education in our disaster preparedness as a country. Infection prevention and control, there’s a huge gap there in our education from medical school days, even during active duty. So there’s a very big gap in those two areas. It really should be standard that we’re prepared and trained in these procedures and not when we face a huge public health crisis. So that is something that I hope to see addressed when we do get through COVID-19.
[00:47:24] Samantha: Definitely. Because I’m class of 2019, so I’m about one year fresh out of med school, not even a whole year, but just looking back, I just recall just having classes on the different types of protective equipment, but not necessarily learning the proper way to put on everything. And it was almost as if we were taught about pandemics and public health crises in a bubble, like, “This isn’t going to happen. The last one was maybe 2003, whatever. But these are some things that will be there to protect you.” And it wasn’t stressed.
But now that we’re in this situation, what I really hope to see when we do come over the hill, is that there’s a lot of policy change. And one of the biggest ones is just– for me, it’s also just how they build health care facilities, where it’s not just– where our healthcare facilities are prepared for situations like this in terms of isolation rooms, having different routes where you can direct persons so they’re not coming in– they don’t have to come in contact with the general population, stuff like that. Just kind of to update how we build or expand our buildings.
And then including stuff like this in our curriculum so that students, when they become new doctors, they already have at least, at minimum, a baseline knowledge of infection control. And that we’re just more– we come out as a cleaner society in terms of handwashing. We have a huge problem with personal space. You’re in the line and someone just hitch up behind you. I’m really hoping that a lot of these things just stick. They stick for us. It’s going to be interesting to see how we progress and how we deal, and interesting to see how we recover because a lot of social issues are coming out. But also, we’re showing a lot of strengths that we have as a country.
[00:49:50] Yohann: Yes. I’ve seen decisive leadership and implementation of various strategies to mitigate this pandemic, really, its impact on our country. And, in fact, perhaps would feel even safer than if I were in some other countries now. So that’s a good thing. But it’s really important for complacency not to creep in, and for us to keep abreast of very new information that emerges every day, and to adjust our strategy as this information becomes available. That’s going to be really important. And also, to be inclusive because discussion generates ideas and, I think, keeps us accountable in this response. So we have to be careful that we don’t fall into the trap of groupthink, and not entertain views that are different from our own because out of those discussions will come innovative ways of responding to this challenge here.
[00:51:03] Samantha: Exactly. I don’t know if you have anything else?
[00:51:07] Yohann: Masks, interestingly, there’s no strong evidence to support that they protect people who don’t have infection, from infection. The mask is really for persons with symptoms or persons who are ill or persons with infection. Let me say that because even if you don’t have symptoms, if you’re found to be infected, you should be given a mask so that you are prevented from having your droplets travel a whole meter or two meters or three to six feet. That is the real purpose of the mask, in holding back the droplets, like literally a physical barrier over your mouth and nose to prevent the droplets from going on to infect somebody else. But if you are not infected, the mask really doesn’t serve you any real purpose, neither do gloves. As healthcare workers, we use gloves once and we discard them immediately after, and then we wash our hands. So for persons that you’ll see walking in the city with their gloves, it really does two things. One, it prevents you from doing what you really need to be doing, which is washing your hands. And it’s also just going to spread germs, anyway, all over the place. And they’re disposable gloves. They should be disposed of after a single use.
So masks and gloves, if you’re not a healthcare worker, really does not provide any real benefit to persons if they’re trying to prevent infection. Washing your hands is going to be– or you do that and cough and sneeze etiquette and staying away from ill people and staying home. That is a strategy that’s used in Hong Kong, which made me rethink the mask issue. But if I were going to support the mask as an intervention tool now, there’s no wide evidence to say that this actually works in Hong Kong. But because they recognize that persons could have no symptoms or mild symptoms and be walking around spreading it, if everybody wears masks, then you would cover the mouth and noses of persons who potentially have infection but no symptoms. And, in fact, one of the professors in a Hong Kong university who discovered SARS back in 2003, commented on that strategy for Hong Kong. But where are you going to get so many masks and doctors don’t have enough masks?
[00:53:32] Samantha: They would also have– we’d also have to talk about proper mask etiquette at that point, where– because if you’re not wearing the mask correctly, if you’re touching your face, if you’re not taking it off when it’s wet, if you’re reusing the same mask, it also almost kind of defeats the purpose. And I think the reality is that we can’t– at this point, we can’t have that strategy because we don’t have the resources here. Because even with that, when we’re doing our mask [inaudible], if I enter a room, as soon as I exit that room, I’m supposed to discard my mask, and if I go back in, I’m supposed to put on– it’s just like me wearing the gloves. As soon as I’m done with that pair of gloves, I need to take it off and put on a new one if I’m going to do something else.
But then, the other thing is, with the masks, we see people walking with surgical masks, but I’ve seen persons in dust masks, painter’s masks. I know persons went online and bought N95 masks. Apart from the surgical and the N95 masks, it’s just like, okay, those are useful. I know that for N95, those are specifically for when we have aerosols, if we’re going to make– if we’re going to do ventilation, intubation, stuff like that. My fear is that– we already heard the Prime Minister talk about persons stealing from the hospital resources to sell, that if we start– maybe if we move—if we don’t properly talk about masks and how they should be worn based on the evidence, then it’s just going to really shorten our supplies. If it was that everybody could get 1,000 masks per person, all right then, that’s fine. But I just can’t– we just don’t have those resources at all.
[00:55:31] Yohann: We don’t and there’s no evidence behind them if you’re trying to prevent yourself from becoming infected. So the public education definitely needs to be there to dissuade people from relying on a strategy that’s not evidence-based. But also, what is very unfortunate is that people can steal from their health sector. And it’s not a new issue. It’s an ongoing, chronic problem, but it is most unfortunate. It is depressing. I don’t know. I just hope that we can put measures in place to prevent easy access to the items that we need. And also, that we can hold these thieves accountable.
[00:56:23] Samantha: The thing is, Yohann, is that when the Prime Minister said, out loud, to the public that persons were stealing, it gave a lot of persons permission to speak publicly about something that we already knew, because each doctor that I spoke to around that time– because when it came out, a lot of the group chats were like, “Andrew say it you know, Andrew say it.” But a lot of us had our own stories about personal protective equipment going missing. As soon as there was an announcement, boxes upon boxes of masks were just gone. And you knew it was somebody within the system because these are places that the lay person or a patient doesn’t have access to. So you know it’s somebody who is actually working at the hospital.
And then it, to me, I– my article last week was about protecting healthcare workers in the face of COVID-19 and it spoke about the fact that everybody who is a healthcare worker needs to be appropriately educated because we’re seeing our security guards, our porters, and stuff, in incorrect masks with incorrect mask etiquette, and also in gloves. So if the doctors are the only ones who know when to properly use them, gloves and mask or otherwise, then that is not going to be enough because you have to– frontline workers also include your securities, your porters, your janitors, your PCAs. Those persons also need to have the appropriate levels of education in terms of how to protect themselves and how the virus can be transmitted.
[00:58:17] Yohann: Indeed. I mean, I just hope that we can hold these people accountable and it’s a most unfortunate thing that says something about us as a society. I was very, very surprised. I [inaudible] words. It’s just unfortunate, but I hope we can stem that practice and that [issue?].
[00:58:44 Samantha: Yeah. So what I don’t want it to sound as, though, is that I’m pinpointing who and who is stealing what, because I don’t know. We don’t know who it is. Could very well be anybody. But if everybody just– I think if everybody had, maybe not the same level, but if everybody had the facts correct, maybe it could help that. But, also, it could help everybody else also protect themselves appropriately. I just wanted to clear that up. I didn’t want anyone to listen to this and say, “Hey, Samantha is pointing fingers.” I’m not. I’m not. But I was very upset when I heard that. I know a lot of persons were, and I can just imagine how frontline workers feel. I currently am not a frontline worker, per se. But I can just imagine how they felt knowing that your stuff is just gone. One day it’s announced one person in the island has it and boxes upon boxes of stuff just gone like that.
[00:59:51] Yohann: Yes. But also to be held accountable are the persons who are buying these boxes of things. If you’re buying something from somebody who’s not a licensed distributor for these things, then you’re complicit in [crosstalk].
[01:00:04] Samantha: Exactly.
[01:00:06] Yohann: So a most unfortunate thing. As I say, I’m very, very taken aback by that observation.
[01:00:20] Samantha: I’m glad that he said it. I think that in this, a lot of things are being kept– I don’t want to say a lot of things, some things are being kept hush-hush, maybe, because we didn’t want to, maybe, put a negative light. So I think that’s why a lot of persons didn’t say out right that these things were happening. So to know that the government is willing to keep people accountable for doing these things, I think it gives us permission to further voice these gaps that we’re having, further voice gaps that we’re not seeing being fulfilled. And it was a good opportunity for them to show that they are responsive because even now, we’re seeing– well, I personally am seeing where more and more persons who have interacted with the hotlines, they’re okay with voicing their concerns with it, or the shortcomings of it. And I just want– I want the government, hospital administration, and everyone who is involved, just to take these criticisms constructively in an effort to basically improve the response.
With the thieving now, we know we need to have better accountability. We need to have stuff maybe locked up, and we need to kind of monitor– and persons who are involved, whether buying or selling, have to have some form of punishment. We know that when persons are increasing the prices of masks, gloves, hand sanitizers, Lysol, that those persons are also kept accountable and places are encouraged to decrease– not really allow person to buy out every single thing. And so we’re seeing all of these mistakes and these little gaps and these what I call “acts of selfishness”, and measures are put in place that can decrease all of this.
[01:02:29] Yohann: Yes. Very important. Very critical. Yeah. But this thing is also different. We’ve not seen anything like this since 1918 when we had the Spanish flu, the influenza that killed about 50 million people worldwide, which is like one 10th of the world’s population. And it’s like a whole replay of that today. Fortunately, we have better technology, for example, [inaudible] sequenced the virus in record time and have that data available for people to make test kits and be able to diagnose it, etc. So we have better technology now, but the challenge is probably just as enormous.
[01:03:17] Samantha: So just to close off, this conversation was really– I really liked it. We didn’t just talk about handwashing. But, of course, definitely want to promote prevention. Wash your hands for 20 seconds with soap. If you’re unable to use soap, use a good amount of hand sanitizer, not just a little toops, social distancing. Don’t go out if you don’t have to. Stay away from persons who are ill. Please, don’t be afraid that if you do feel ill or know someone who is ill, just to contact the emergency hotlines, which will be linked in the show notes. And for healthcare workers, you know I’m always batting for us. Make sure that you know your hospital protocols or your health center protocols. Ensure that you go to your trainings, that you feel appropriately trained, and that you are comfortable. Don’t be afraid to speak up. Don’t put yourself at risk and don’t put persons at risk, patients at risk. You have any closing remarks, Yohann? Anything that you want? Where can we find you? If you want to do that.
[01:04:42] Yohann: I’m just grateful for this opportunity to have this discussion. I think we need to have more discussions like this and people should be encouraged to share their ideas and to– if they see gaps in the response in their communities, it’s really important to speak with their representatives and share their ideas and point out these concerns. I can be contacted on social media. My social media handle is @CaribeWellness. So Caribe as in the first part of Caribbean, Wellness, CaribeWellness. And that’s on Twitter, Facebook, and Instagram.
[01:05:23] Samantha: Okay, thank you so much for coming in. I really appreciate you coming on here and having this conversation with me. I think this will be the first of many conversations about– at least on my side, about the coronavirus. I know that other medical personnel have been going on other places, just– on TV, online, talking about it. I’m loving this new-age social media. The fact that we can share information so quickly and that a lot of doctors are willing to share information and to use their platforms to share correct information as well.
[01:06:11] Yohann: Yeah. It’s also a learning process for me, but I really try to follow the information that’s coming out because when you’re deep in the response, I’m afraid it seems that they don’t have time to follow the science. And then you’re seeing these gaps, so.
[01:06:28] Samantha: The information is overwhelming because every day I get something new. And I’m just like, “I haven’t read everything about this.”
[01:06:39] Yohann: We’re all going to be corona virologists after this [laughter].
[01:06:44] Samantha: Yes. If you want to follow me or reach out to me, you can do so on social media. I’m on Instagram and on Twitter. I’m @thelaymansdr. That’s written as @thelaymansdr. If you have any comments, questions, you might be featured on one of these episodes, please email me at thelaymansdoctor@gmail.com. And on any platform that you’re listening to this, please subscribe, rate it, and don’t forget to leave a review. Stay safe out there. Practice your social distancing. Practice your handwashing, proper handwashing techniques. Thank you so much for listening. Until next time. [music]
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