Editor’s Corner: At World’s End

David Steensma, MD
Edward P. Evans Chair in MDS Research and Institute Physician at the Dana-Farber Cancer Institute; Associate Professor of Medicine at Harvard Medical School; Editor-in-chief of ASH Clinical News

Just before the first deaths from the SARS-CoV-2 virus were reported in the U.S. and the Commonwealth of Massachusetts declared a state of emergency, my wife and I went for a Sunday afternoon hike in a park south of Boston called World’s End, which now seems prophetic. In 1945, World’s End was short-listed as a possible site for the headquarters of the United Nations, but it was beaten out by the Turtle Bay neighborhood in Midtown Manhattan. Now the nations of the world are united against a common enemy – 30 kilobases of self-replicating single-stranded RNA – while billions of people have withdrawn into their homes like anxious turtles hiding in their shells.

My first editorial in a then-new publication called ASH Clinical News appeared in May 2015. It was about the joy of seeing blood cells under the microscope – a heartfelt remembrance that now seems rather quaint. I have written more than a dozen essays for this magazine since then, but I have never struggled as much with what to say as I have this month.

For the past few weeks, each time I decided on a topic to explore in this column and began typing, the chosen subject soon seemed insignificant amid a growing and unprecedented global health crisis. In the face of this emergency, we’ve been reminded how little words matter compared with actions. In those small snippets of free time stolen from the chaos, I am also finding it hard to concentrate – maybe you have noticed that, too?

Perhaps it is best just to acknowledge the Giganotosaurus in the corner of the room and face it head on.

But what exactly are we facing? There are a few centenarians out there who witnessed the “Spanish flu” of 1918-1919 as young children, but the rest of us have never experienced a global pandemic of this magnitude.

We could and should have seen something like this coming, and some did. For example, biotech investor Brad Loncar predicted a pandemic in his December 2019 list of “10 Things Likely To Happen In 2020,” while novelist Dean Koontz wrote about a dangerous virus called “Wuhan-400” in a 1981 thriller. Still, seeing this event coming would not have made the reality of it any easier to bear, nor would it have helped us predict what will happen next.

In addition to killing tens of thousands of people from China to Canada to Chile – perhaps the worldwide death toll will be in the millions by the time this essay is in print in May – COVID-19 has harmed the world’s economies and altered its social fabric in ways we won’t fully understand for many years. Our hematology patients who have gone through hematopoietic cell transplantation have watched as the rest of the world adopted the “social distancing” and infection precautions that are so familiar to them.

For physicians, nurses, and other health-care workers, the pandemic has completely disrupted how we practice medicine and go about our daily work. I never imagined I would begin each day waiting in a queue at the door of a hospital, carefully marked with masking tape lines placed 6 feet apart, to be screened by security and receive my mask for the day. That daily mask ration has become something I take more care of than my smartphone, even though the phone is 1000 times more costly.

The pandemic also has upended our routines outside the hospital and clinic – especially if we have children who are now home from school indefinitely. Many of us have already lost friends, acquaintances, or loved ones to the virus, and there will undoubtedly be more grieving to come.

The worst of humanity has been on display amid this crisis, as happens in all disasters. We’ve seen hoarding of food, toilet paper (!), personal protective equipment (PPE), and – at least in America – guns and ammunition. Doomsday preppers, who have endured years of ridicule, suddenly don’t seem quite so outré. We’ve witnessed far too much willful ignorance from political leaders, suppression of data, and spreading of disinformation. The reputation of the Centers for Disease Control (CDC) – its laboratories still full of terrific staff scientists and technicians, but its leaders muzzled and its managers influenced by lightweight partisan appointees – will take a long time to recover from this debacle.

The Crazy Uncles and charlatan healers of the world have been busy touting unproven COVID-19 therapies on social media and television, citing misleading data and hyped-up anecdotes. Too many otherwise-intelligent doctors have been willing to throw the principles of evidence-based medicine into the trash heap along with the piles of used N95 masks and isolation gowns. Sensible recommendations to stay at home and practice social distancing were interpreted by far too many as opportunities for bargain-barrel rates on cruises and flights and “deserved” Florida beach trips. Our children and grandchildren have been saddled with trillions more in public debt to repay.

Many of the pathologies of American medicine are being magnified by the crisis. Hospitals that were already at capacity before the pandemic are pushed to the breaking point… and beyond. Electronic medical records that were obnoxiously clunky and cumbersome before COVID-19 are now dangerous barriers to clinical efficiency. The U.K.’s chronically stressed National Health Service has pulled retired physicians into service and clinician-scientists out of the lab and, as I write, military-style field hospitals are being set up in New York’s Central Park and in many other cities. The rich and well-connected somehow got access to coronavirus tests while others struggled to do so – then fled to island homes and private yachts. Desperate nurses have been photographed using trash bags as makeshift PPE in a hospital in New York that has been overrun by hundreds of patients with COVID-19. Meanwhile, the hospital network’s CEO was found to be working from his waterfront mansion in Palm Beach, afforded by his more than $6 million annual compensation.

There is a silver lining: HIPAA enforcement and penalties have been suspended temporarily, long-maligned JCAHO achieved brief heroic status when it advocated for health care workers to be permitted to wear masks, the American Board of Internal Medicine has put maintenance of certification on hold, and the National Institutes of Health (NIH) and other funding agencies delayed grant submission deadlines. I haven’t heard an administrator mention relative value unit targets in months.  For many of us, commuting into the clinic or hospital has gotten much shorter as road traffic has evaporated.

We’re also seeing the best of humanity. Nurses and nurse practitioners, respiratory therapists, physician assistants, laboratory technicians, phlebotomists, doctors, environmental service workers, security staff, and so many others are putting themselves at real risk to save lives. Necessity is the mother of invention, and the past few months have been a particularly fertile time for creativity and innovation. Trials of vaccines and novel therapies for COVID-19 have opened more quickly than clinical trials ever have before, while biotech firms work overtime to develop new approaches.  We may witness the shortest period in history between identification of a novel pathogen and widespread deployment of a successful vaccine. Ventilator components are being created with 3D printers; manufacturers that normally make automobiles or vacuum cleaners are retooling to make needed medical equipment, while those that normally make pillowcases or garments are producing masks and gowns. Laboratory-based scientists who are no longer able to work at their benches are filling the gap with free video seminars to share information, like the hematology-themed “Blood and Bone Seminar Series” organized by Kellie Machlus, PhD.

There also have been beautiful displays by the general public: music from balconies, coordinated applause for stressed hospital workers, donations of PPE. We’ve been reminded who the “essential workers” in society truly are: the grocers, bakers, truck drivers, and millworkers who actually make things and keep supply chains running – those who do the jobs depicted in Richard Scarry’s 1968 children’s classic, What Do People Do All Day? At my hospital and many others, local leadership has been proactive and excellent, and everyone is pitching in where they can. Many hematologists are staffing general medical teams and “Special Pathogen Units,” often continuing to care for patients despite risk to ourselves from older age or personal medical conditions.

I’m hoping the better angels of our nature will continue to prevail and that when all is said and done a major event like this will be a chance to reconsider some of our societal priorities.

Take career choice, for example. For the past 15 years, the most common goal for students graduating from elite universities has been to work in finance, banking, or management consulting. That needs to change. Money makes the world go round and stewardship of it is necessary, but money is a means to an end, not an end in and of itself. Hodgkin lymphoma expert George Canellos, MD, emeritus faculty at Dana-Farber Cancer Institute, who has seen many groups of special consultants come and go over the years, likes to say that asking a management consultant how to improve the way you work is akin to showing someone your wristwatch and having them tell you what time it is. Imagine instead if we saw the best minds of this generation consistently going into science, medicine, engineering and the humanities. To realize this, we need to work collectively to make these fields less of a slog.  For example, science and medicine are perceived as too difficult, the training too long and risky, and the likelihood of reward too low.

Personally, the sense of relief I’ve felt at cancellations of meetings and conferences has made me rethink how many I had committed to go to in the first place. I know I am not alone in that. There is certainly nothing like an in-person meeting to promote collaboration and exchange ideas, but there are just too many medical and scientific conferences now. Once the machinery of civilization gets going again, I plan to take a travel sabbatical, going only to meetings sponsored by the American Society of Hematology (ASH) and the foundations that fund my work, and to be more selective as I reincorporate others down the line.

Something else we might reevaluate is the value placed on sports versus other endeavors. I love baseball, basketball, and football as much as the next person; I grew up playing Little League baseball in view of the New York City skyline, envisioning myself in pinstripes on the infield dirt at Yankee Stadium someday, snaring wicked line drives in the webbing of my outstretched glove. But with professional sports leagues furloughed, ESPN is left to televise stone-skipping and sheep-shearing competitions, lumberjack challenges, and Jelle’s Marble Runs.

As the death rates from COVID-19 began to rise and the stock market dropped almost 30%, 42-year-old New England Patriots quarterback Tom Brady signed a 2-year, $50 million guaranteed contract with the Tampa Bay Buccaneers. He may be the G.O.A.T., but in the context of what was going on across the country, that figure seemed obscene. Last year, the cumulative direct revenue for the four major U.S. sports leagues exceeded $40 billion: $16 billion for the NFL, $11 billion for the MLB, $9 billion for the NBA, and $5 billion for the NHL. The total NIH budget for fiscal year 2019: $39 billion. Which do we need more?

There have been many times in history when plagues have ended wars, from the Peloponnesian War in 430 BCE to the way the Black Death ended several long wars in medieval Europe.  U.S. conflicts in Afghanistan and Iraq have cost at least $2.4 trillion since 2001 – and, sadly, left us with thousands of wounded veterans and bereaved families. Yet there was not enough funding allocated to continue the CDC’s $20 million per year PREDICT program for early detection of emerging pathogens, including zoonotic viruses.  Perhaps this can be another time when a disease ends a war that has long overstayed its welcome.

We can’t fix what has already happened, but “the old world is dying, and the new world struggles to be born.” We can hope and work for a better future and the end of the old.

For now, back to work, and back into the breach.