'Massachusetts Strong' COVID-19 Response

Neil Osterweil

May 29, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The emergency field hospital at the DCU Center, a sports, entertainment, and convention complex in Worcester, Massachusetts, discharged its last COVID-19 patient at 11:07 am on Tuesday, May 20. John Broach, MD, MPH, and his colleagues breathed a sigh of relief.

"We've had the last hour or so to decompress, move equipment out, and we're happy that we were able to discharge the last patient in good condition," Broach told Medscape Medical News within an hour of that patient's discharge.

"We're seeing a very slow decline day over day in terms of the number of hospitalized patients," Broach said. "When I work in the emergency department, I have started to see fewer patients there clinically with COVID, and that's a good trend that hopefully will continue," he said.

The field hospital is being run by University of Massachusetts Memorial, the medical school's teaching hospital, and they're keeping it in turnkey condition, ready to open again at a moment's notice should there be a surge in COVID-19 cases.

As the Commonwealth of Massachusetts, one of the states hardest hit by the COVID-19 pandemic, slowly begins to restart economic activity through a four-phase re-opening plan, emergency response and infectious disease experts remain on guard.

"I'm a disaster medical guy, so I'm always worried about this kind of thing," Broach said. "But I think that, on balance, the approach that the state is taking is reasonable, and it allows us time between each stage to evaluate whether the previously opened phase is successful or if we're starting to see a resurgence."

Declining Curve

"It's been a busy few months," said James Hudspeth, MD, FACP, the COVID response inpatient floor lead in the Department of Medicine at Boston Medical Center (BMC).

BMC is the city's safety-net hospital, and is affiliated with the Boston University School of Medicine. At the height of the surge in mid-April, 70% of admitted patients had severe COVID-19 infections.

Beyond the medical center, the city opened up another field hospital at the Boston Convention and Exhibition Center, normally host to medical meetings and trade shows. The venue had approximately 150 of 1000 beds occupied by patients recovering from coronavirus who needed a lower level of care, and homeless people who had no other shelter-in-place options.

As the city eased into May, the numbers began to decline. "We're definitely seeing some headway here," Hudspeth said in an interview with Medscape on the Friday before Memorial Day. "But it's interesting because we're also seeing a return of some of our non-COVID volume. So it's a bit of a balancing game."

Like Broach, Hudspeth is guardedly optimistic about the medical system's ability to cope as lockdown restrictions ease.

"It's reasonable to predict that we might experience some increasing cases once we start lifting some of the social-distancing guidelines. I think it has been weird to see the heterogeneity across different American cities around this," he said.

On Memorial Day weekend, while other areas of the country saw thousands of unmasked vacationers, such as at hotel pools in Lake of the Ozarks, Missouri, and on the shores of Port Aransas, Texas, Massachusetts stood in stark contrast. The state's beaches and parks were only sparsely occupied and the normally busy highways remained relatively traffic-free.

"We're all obviously a lot more COVID-conscious in Boston," Hudspeth said. "I think it's also reasonable to say that with a phased response, with people taking the right kind of precautions, maybe we won't really see much of a surge coming back."

Mild Winter, Turbulent Conditions

The winter of 2019/20 was one of the mildest on record for Boston, with little snow, and relatively high temperatures for much of the season. The city's hospitals, however, were under a cold, dark cloud through March, April, and into May.

The first known case of COVID-19 infection in Massachusetts was identified on February 1 in a man in his 20s who had returned to Boston from a trip to Wuhan, China. His symptoms were relatively mild, and he recovered after self-isolation, without hospitalization.

But that was only the beginning of a long and sorrowful story. On February 26, an otherwise mundane meeting held at a harborfront hotel of about 175 executives from the biotechnology company Biogen became a notorious "super-spreader" event, accounting for 70 of 92 confirmed cases in the state as of March 10. In addition, participants in the 2-day conference — who came from Indiana, New Jersey, North Carolina, Tennessee, and Washington, DC — carried COVID-19 home as an unwelcome reminder of their visit. It is also suspected that the meeting was the source of cases in participants from, Argentina, Austria, and Germany.

By Memorial Day, May 25, there had been 93,271 confirmed cases of COVID-19 and 6416 deaths. However, by all metrics published on the Massachusetts Department of Public Health's COVID-19 dashboard, the total confirmed-case numbers have trended slowly downward since May 1.

Boston is the third most densely populated city in the United States, after New York City and San Francisco. Yet despite the proportionately high number of cases, Massachusetts is well-equipped to deal with medical emergencies. Boston, the state capital, is small compared with New York City, with just over 710,000 residents, and it's home to three major medical schools — Harvard, Tufts, and Boston University — and their affiliated teaching and research hospitals. Healthcare is the largest industry in Boston, and Massachusetts has the highest proportion of healthcare personnel per capita of all 50 states.

Nonetheless, preparing for the inevitable surge of cases in the absence of a national strategy was reportedly harrowing for the state's clinical and political leaders.

On March 15, Massachusetts Governor Charlie Baker ordered the closure of all public and private schools for at least 3 weeks. On March 23, he issued a stay-at-home advisory and closing orders for nonessential businesses, both of which were eventually extended through late May.

And on April 3, Baker announced that the state, in collaboration with the Boston-based nonprofit Partners in Health, was hiring and training as many as 1000 people for one of the nation's first COVID-19 contact-tracing programs.

But officials say the state's efforts to control the spread of the virus were thwarted at times by the federal government, such as when the Commonwealth secured shipments of hundreds of N95 masks and 35 ventilators that were subsequently seized by a Federal agency; the governor did not specify the Federal agency involved.

PPE Orders Disappear

At the March 27 press conference, when Baker announced the seizure, the state's Secretary of Health and Human Services (HHS), Marylou Sudders, revealed that a shipment of 3 million N95 masks acquired by the Massachusetts-based BJ's Wholesale Club that had arrived in the Port of New York and New Jersey for shipment to the Bay State were also impounded by an unnamed Federal agency.

The normally mild-mannered, seemingly unflappable Baker stopped just short of swearing. "We've literally gotten to the point where our basic position is that until the God…until the thing shows up here in the Commonwealth of Massachusetts, it doesn't exist."

Just a few days later, however, a Boeing 767 jet owned by the New England Patriots football team touched down at Boston's Logan Airport with a million masks from China.

But PPE couldn't shield against established health disparities that put communities at risk. During the pandemic, more than 80% of the patients admitted to BMC were black or Latinx, a stark reminder that minority communities have been hit especially hard by COVID-19.

Minority Communities Hard Hit

Alister Martin, MD, MPP, an emergency physician at Massachusetts General Hospital and faculty member at the MGH Center for Social Justice and Health Equity at Harvard Medical School, saw first-hand how a public health policy meant to help in a crisis can actually be discriminatory and inequitable.

"I was at a faculty meeting of the Department of Emergency Medicine and we had someone come and present about what is now known as the Crisis Standards of Care," he said.

Developed by HHS, the Crisis Standards of Care offers guidance for providing medical care under catastrophic conditions, when resources may be limited.

"They told us they wanted us to answer two questions when it came to patients who had COVID-19. The first question was: How sick is the person with COVID? How sick are they right in front of you, which is a reasonable question to ask," Martin said.

"The second question they wanted us to answer was: Who was this person before they got COVID? What kind of diseases did they have? And for each of these diseases, the patients actually get points. The more points you get, the less likely you are to get a ventilator," he said.

Patients with chronic conditions, such as diabetes, lung disease, and HIV, would receive a score of two points for each condition. "These patients who get the diseases on the list that was put in front of us are disproportionately people of color," as well as low-income citizens with poor access to affordable healthcare, Martin said.

"It seemed to me that we're now going to be holding that against people, and withholding life-saving treatment from predominantly black and brown folks," he added.

The recommendations were also deeply troubling to cancer survivors, people with disabilities, and others with chronic conditions, who saw themselves being cast as second-class citizens.

Last on the Ventilator List

To combat this, Martin and colleagues from other hospitals and health centers in the area formed what he calls a "grass roots and grass tops" effort to change the policy, beginning with an open letter with a thousand signatories urging Governor Baker and state health experts to reconsider the guidance.

"On April 20, the governor released new guidelines, which in effect didn't address all of the problems that we had pointed out, but did a pretty good job of moving the conversation to more of a health-equity focus," Martin said. "This was a pretty awesome thing, doctors coming together and saying, 'Nope, you can't do this,' and the government saying, 'You're right, let's take a look at it again'."

Another area where Massachusetts health authorities pushed back was in the distribution of remdesivir, an experimental antiviral agent from Gilead Sciences.

"We initially received federal allocations of remdesivir and they went to a small number of hospitals in the state, but were not necessarily appropriately allocated," said Lawrence C. Madoff, MD, medical director of the Bureau of Infectious Disease and Laboratory Sciences at the Massachusetts Department of Public Health (DPH).

According to a story in The Boston Globe, Mass General, which had 344 patients with confirmed or suspected COVID-19, was told that it would receive enough remdesivir to treat approximately 170 patients for 5 days. Yet other Boston hospitals with similarly high populations of severe COVID-19 patients did not receive any remdesivir at all, including Beth Israel Deaconess Medical Center, BMC, and Mass General's sister institution Brigham & Women's Hospital. Meanwhile, two other regional hospitals with smaller numbers of COVID-19 cases received more doses than they would likely need.

Hospital leaders recognized the disconnect between need and drug distribution and worked closely to reallocate it, Madoff said.

As part of that initiative, the DPH formed a remdesivir working group that meets regularly to distribute medication to hospitals based on need.

"I have seen our public health team at its strongest during this outbreak," Madoff said. "The whole team I work with at DPH have done an astounding job at rising to what has been an almost crushing situation, something we've really never seen before."

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