Amplify Nursing Special Episode: Coronavirus Transcript

Alison Buttenheim:

What things look like in two weeks or two months depends on what we do today. It’s not just we have to wait and see what happens. We can take action now, especially around the social distancing, so that two weeks from now things look better than they would have if we hadn’t done those things.

Angelarosa DiDonato:

Hello everyone. I’m Angelarosa DiDonato.

Marion Leary:

And I’m Marion Leary.

Angelarosa DiDonato:

And you’re listening to Amplify Nursing, a Penn Nursing podcast supported by the Pinola Fund for Innovation in Nursing.

Marion Leary:

Amplifying Nursing features nurses who are leading the way in science policy and innovation.

Angelarosa DiDonato:

Our guests defy stereotypes, define practice, and disrupt invention.

Marion Leary:

We highlight the breadth and depth of nursing influence on society by amplifying nurses who are pushing boundaries and breaking down barriers to build a new paradigm.

Marion Leary:

On this special episode of Amplify Nursing, we talk with public health researcher and behavioral epidemiologist Dr. Alison Buttenheim and social epidemiologist Dr. Carolyn Cannuscio. Dr.Buttenheim is an associate Professor of Nursing at the University of Pennsylvania’s School of Nursing and Assistant Professor of Health Policy at the Perelman School of Medicine. Dr. Cannuscio is the Director of Research for Center for Public Health Initiatives and an Assistant Professor of Family Medicine and Community Health at the University of Pennsylvania. Today they’ll discuss the coronavirus, what we need to know, what we need to do to help lessen the spread, and what we should expect in the days and weeks to come.

Angelarosa DiDonato:

Alison and Carolyn, thank you so much for coming to talk to us today about everything that’s going on with the COVID-19 virus spread. Alison, how about you talk to us a little bit about what exactly is going on with the spread?

Alison Buttenheim:

Thank you so much for having us. What really strikes me with this coronavirus outbreak is how fast the situation is changing. I was looking back today at some of my tweets from three days ago or five days ago and it seems like a different world already. And I think as of today that the wider community is hearing the message about how important social distancing is. And we tell people, "This is going to be a phrase you’re going to be sick of hearing, but we’ve got to get people not to be in the same place at the same time." And that’s what it’s going to take at this point, another phrase people are sick of hearing, to flatten the curve and that just means slow down, delay, or postpone as many cases of the virus as possible so that our healthcare system isn’t overtaxed.

Alison Buttenheim:

And what does social distancing look like? Well, the extreme versions of it are closing schools and asking employees who are able to work at home but also avoiding big events, avoiding shopping in crowded areas, not having that dinner party, not going to that performance. And that’s a big change in people’s daily lives. And I think it’s been hard for people to kind of absorb how important it is, but it’s really, really important.

Carolyn Cannuscio:

I’ll just add to what Alison said. This is Carolyn and thank you so much for having both of us. My family was traveling in Italy just under a month ago, and the first few cases of COVID-19 were diagnosed in Northern Italy at the same time that my family was traveling there, my extended family. And of course there was concern at that time, but that concern has escalated so rapidly. And I know that I am highly motivated right now to get the word out with Alison and with you about the importance of social distancing so that we can protect our communities, and our healthcare workers, and our healthcare system from the absolute tragedy that’s unfolding in Italy right now.

Carolyn Cannuscio:

It’s so important because Italy is a lot like the US in some ways, in terms of the number of hospital beds and physicians per capita, in terms of the ways of social life and the prize that we all place on freedom to do as we wish, but right now the nation is in lockdown and healthcare providers are being forced to make excruciating decisions about rationing healthcare, rationing ventilators. The only way that we are going to prevent that situation from happening in the US in the next days and weeks is to take aggressive action now. Alison, what are you hearing in the community about steps people are taking or are resistant to taking to participate in social distancing?

Alison Buttenheim:

That’s a great question. I mean, I’m hearing a lot of questions. People are just kind of messaging me, sending texts or sending tweets, really wondering how to cope with, for example, school closures. So one set of questions I hear is, do school closures really make a difference? We’ve heard that kids aren’t as susceptible to COVID-19. Maybe they don’t play as much of a role in transmitting it in the community. Why is it so important to close schools? And my response is, every step we can take to reduce social contact helps. So for example, one question I heard is, "Our school is considering closing, but if we close and other schools don’t close, does it help?" It helps, because that takes that school’s community of kids out of the social mixing every day.

Alison Buttenheim:

Another completely different set of questions that are so important is, what are the social costs, especially to vulnerable families, when we close schools? How will these kids eat if they get their breakfast and lunch at school? What if these kids’ parents have to go to work? They don’t have a work at home option like many, many of our workers in the US don’t have that option. How will those kids be cared for, be safe if schools close? And I really feel like we have to very quickly think of creative and effective solutions so that these are both/and solutions. We both close the school and we put some safeguards and safety nets in place so kids are fed and safe.

Carolyn Cannuscio:

Thank you for saying that, Alison. Our group at Penn did some research on the impact of short-term school closings on access to meals for children here in Philadelphia. We are the poorest of the 10 largest US cities, and children in our public schools are eligible for universal free lunch and breakfast. If schools in Philadelphia are closed for just three days, that translates into over 400,000 meals missed among Philadelphia school children. And I like the way you’re thinking about trying to identify solutions that allow us to engage in social distancing by closing schools and getting those children and teachers and staff out of those crowded school buildings, but we also can, for example, think about loosening some of the regulatory restrictions on how school lunch is delivered. Right now my understanding is that school lunches must be delivered in a congregate meal setting and that is exactly the kind of environment we’re trying to avoid in the context of this epidemic.

Carolyn Cannuscio:

What if we could loosen that requirement and have the meals available at school for students or families to take away back to their homes or what if we could set up drop off to students’ homes? And I think we should be imagining creative solutions. In addition, I would encourage every philanthropically inclined and able person to give money right now to a local food bank. The food banks are in a better situation than we are in to procure food at a lower cost and to distribute that food to their clients. They also know the kinds of foods that their clients need to receive week to week, so I highly encourage us to call upon our greatest generosity in communities across the country and to give to the food banks and to the Red Cross so that in addition to regulatory changes at the federal and state and local levels and action on the part of our government, we can also support the nonprofit organizations that are really lifelines every day for vulnerable populations.

Angelarosa DiDonato:

These are fantastic points I feel like aren’t being touched upon when the conversation is being had throughout the media or even social media. Can you just explain, everyone’s talking about the social distancing and that we should be doing it, but can you explain why it’s important for people who maybe don’t understand that and can you also talk a little bit about some of the pressure that the healthcare system is going to see as this pandemic kind of escalates?

Carolyn Cannuscio:

The basic concept with social distancing is that viruses thrive in groups of people and viruses thrive in groups of people that mingle and move to new places, so we want to deprive an infected person or that virus the opportunity of encountering a susceptible host. And right now we are a globe filled with susceptible hosts. Our nation is completely vulnerable. We have no immunity to this virus. We have no vaccine, so our only hope is to identify people who are sick, who have the infection with the virus that causes COVID-19, and to isolate those people, or, given the terrible situation in the US right now with limited testing, we have to assume that the virus is circulating in our communities.

Carolyn Cannuscio:

We have to assume that people at our workplace, people in public settings, people at our children’s schools are already infected. And what does that mean? That means we need to stay away and we need to turn private. We need to take ourselves out of the public sphere. We need to limit all of our social contacts in order to stop the virus in its tracks, in order to deprive it of the next place to go. Alison, would you add anything to that description of what social distancing is all about?

Alison Buttenheim:

I can add just another really good metaphor I heard today and I’m going to attribute it to Andrew Noymer, a sociologist. Andrew said we’re a big glass of milk. Our country, our world, we’re a big glass of milk, and the coronavirus is like drops of red food coloring that are being dropped into that glass of milk. And our daily lives, our congregating, our social contact is like a swizzle stick that goes into that glass and stirs it up and turns the milk pink, spreads that virus all the way through the glass of milk. What we want people to do is not stir the milk. Don’t be the swizzle stick. Every action you can take to let that glass of milk just sit there and not have the red drops of food coloring mix with the milk, the fewer cases we’ll have. And again, importantly the less stress on the health care system as a whole bunch of cases go into hospitals at the same time.

Carolyn Cannuscio:

That was a great answer Alison, and I’m reminded of the kinds of questions that are coming at us quickly from ... Today I got a call from the Pennsylvania Prison Society. We have heard from the schools, we’ve heard from workplaces, and we’ve heard from individuals, and people are asking questions about what their institutions should do to define social distancing and to establish policies and individuals are trying to think about what they should do, the decisions they should make. And one thing I really want people to think about is that we should all think of ourselves as policy makers right now. So if we run a workplace, if we run a lab, if we are a member of a religious congregation, wherever we operate in society, we should be thinking about trying to lay down some clear rules that people can use to make decisions about their own behavior.

Carolyn Cannuscio:

And why is that so important? Alison is a behavioral scientist who can really add to this concept, but one thing I’m struck by right now is that so many people are putting so much cognitive effort into trying to make these difficult decisions. Should I attend this bat mitzvah? Should I take my family on spring break? Should I work from home or should I go to the office to this very important meeting with a client? What good policies can do is they can help people make some of those decisions without exerting so much effort. They can also help enforce a social norm that says, "We’re all in this together and we’re all going to adhere to these same rules."

Carolyn Cannuscio:

Right now I’m recommending to people that they establish these rules, that they follow these rules about social distancing and that they try to defer any big decisions that they don’t have to make today. People should really take their energy and focus on, "How can I take myself and my family out of the social equation? How can I take myself and my family out of this numbers game where the virus loves lots of people?" I want people to think about the basics, their needs, their family’s needs, and policies will help people waste less energy focusing on trying to make these decisions. I don’t know. What do you think about that, Alison?

Alison Buttenheim:

I think that’s a great perspective, and I’ll just add again from the sort of behavioral science perspective, I too have gotten a lot of individual questions. One I got last night was a parent whose teenage son had bought tickets for himself and his girlfriend to go see a show at a big venue in Philadelphia, and the parents were trying to decide if they should either strongly encourage or actually forbid the teens from going to this big venue. And they were asking me for sort of the evidence about social distancing. And I said, "Here’s the evidence and it doesn’t sound a lot like pulling two people out of this big venue was going to help, but it is. And we really need to be making those individual decisions." But wouldn’t it be better if the venue made the decision, one decision, to cancel the event?

Alison Buttenheim:

And I really think we need, in addition to individual households and families thinking about how to enforce social distancing for themselves, we really need institutions and governments to step up and make the policy decision that just makes it much easier, as Carolyn said, for people not to have to make all those individual decisions. We actually saw that today. The governor of Pennsylvania made some decisions about Montgomery County, which is the County in Pennsylvania that’s had the most COVID-19 cases so far. He has closed schools, universities, gyms, entertainment venues and community centers for two weeks, starting tomorrow, and he’s also asked all non-essential retail stores to close. That’s a great decision. That’s a bold decision. That is obviously a decision with economic consequences for a lot of people and convenience consequences, but it is a step that alleviates all those Montgomery County residents from having to make a zillion individual decisions about social distancing every day.

Angelarosa DiDonato:

Yeah, that was a very bold decision by Governor Wolf today and hopefully we’ll start to see some other counties following suit. I was talking to a friend in Ohio who it sounds like they’re pretty much doing the same thing in Ohio throughout the state, trying to avoid any further issues. Can we talk a little bit about the strain that this will put on the healthcare system if we don’t start doing of these things?

Alison Buttenheim:

I don’t want to scare people. I really don’t want to scare people, but I will say that I was worried about this virus and this disease and this outbreak and now this pandemic, as WHO has finally declared it. I had a lot of worry about it until about three days ago, and then three days ago I actually got scared. And what scared me was two things, the numbers in the US, that the daily increases in numbers of cases, identified cases, that we were seeing that starting to look like that hockey stick where we have some cases and then it shoots up the graph and the stories from Italy, to return back to Carolyn’s comments earlier about Italy, and the physicians having to make choices about who gets the ventilator. We have elderly people, frail, elderly people. We have people with chronic conditions. We have some healthy adults who are sick and having to decide who’s going to benefit from a ventilator or an ECMO machine. Cause there’s no cure. You just have to kind of have it run its course and not have the lung disease that can develop be so dangerous. Reading those firsthand accounts from doctors in the Italy system made me worry about what this could look like here if we started overburdening our ICUs and our hospitals with these cases.

Carolyn Cannuscio:

I’ll also add that it helps me think about my motivation for speaking up about this when I imagine the people I love who are the healthcare workers, who are going to be in the emergency departments responding when an influx of patients comes in and there are many people who are in dire straits. I’m thinking every day about what we in the community can do to protect those healthcare workers, and I’m talking about doctors and I’m talking about nurses and I’m talking about respiratory therapists and I’m talking about the people who clean the hospitals. I’m talking about the people who feed patients. I’m thinking about the administrators who are trying to figure out how to get enough personal protective equipment for healthcare workers.

Carolyn Cannuscio:

And it motivates me to speak up like I really have never spoken up before in my career because we need a sense of urgency and we need it across the country and we need it absolutely right now. We need our leaders to step up and say, "Every single person who can participate in social distancing should do that aggressively and to the best of their ability, and we should really be thinking about how we can help others through this crisis." I feel motivated because I know those people, and I also feel motivated because I understand that in Italy there are requests for doctors to come out of retirement’s help and those doctors who are in retirement are in a very high-risk group. I also understand that there may be efforts to accelerate the graduation of nursing students in Italy so that they can provide support on the front lines. We’re talking about conditions that we have not experienced in our lifetimes. I’ve read about and taught about epidemics through history and it feels like we’re living through yellow fever in 1793 in Philadelphia and all members of the community have to work together to solve this problem. It’s not a problem we can leave for the healthcare system to solve.

Angelarosa DiDonato:

Right. There are excellent points and extremely valuable lessons that we should be learning from the progression of the disease in Italy. What kind of resources should people be looking to for information if they need help with making decisions until entities start doing that for them?

Alison Buttenheim:

Outbreaks like this are really local affairs, even though they’re widespread across the country right now, and I think one first place to go to bookmark is your local health department. Every one that I have visited, and I visited several of these websites over the past couple of weeks, has a link to their coronavirus update page right on the front. Local health departments are differently resourced across the countries but most can tell you what’s the current guidance to healthcare providers? What’s the current guidance to schools, to individuals? I just looked at the Pennsylvania state one today. They provide testing information, how many people are being tested and what are those results? Lots of links to to-the-minute updates from the CDC. So if you can stay local with your updates, that’s great.

Alison Buttenheim:

And then a second place, and this is another interesting phenomenon during this outbreak, is your local newspaper. So again, in our case in Philadelphia, the Philadelphia Inquirer has fantastic coverage of the outbreak and, very laudably, they have pulled that coverage out from behind their paywall so that everybody has free access to their COVID-19 coronavirus coverage. One responsibility that puts on all of us is to now subscribe to those newspapers and outlets because they obviously can’t do that reporting for free, but the fact that they’re making that coverage widely available to everyone is a reminder to all of us to really support local journalism outlets like the Philadelphia Inquirer.

Carolyn Cannuscio:

Absolutely. And I think that it’s also useful to listen to scientists right now. I go to three different universities for my information about this outbreak. I go to the University of Minnesota where their Center for Infectious Disease Research and Policy has a great website with synthesized scientific information written for the laypublic. I find that incredibly useful. In addition, the Johns Hopkins Center for Health Security has excellent resources, often translated well for the public. In addition, the Harvard School of Public Health and Dr. Mark Lipsitch provides excellent up-to-the-minute reporting on the COVID-19 outbreak. Their Center for Communicable Disease Dynamics is another great resource. I would just say that I am an ally with our state and local health departments. I consider that every member of the public health community right now is activated on high alert and wants to do the right thing.

Carolyn Cannuscio:

We will make mistakes in our communications. I think that we need to correct those mistakes when we make them. And very recently in Philadelphia, our own health commissioner made one of those mistakes by cautioning Philadelphians to avoid large gatherings, which he operationally defined as gatherings of 5,000 or more people. I would say that given the crisis that’s unfolding right now in our nation, he was wrong by orders of magnitude and he should walk that back. What I mean is it is not safe to be in a gathering of 4,999 people. There is no clear threshold at which risk is present or absent. I would say that we should be limiting all social contacts as much as possible. Alison, I don’t know what your feelings are about that particular communication, but I’d love to hear.

Alison Buttenheim:

Yeah, and I think, Carolyn, you’ve been doing a great job on social media, on bringing attention to those decisions and rallying support for policy makers to update their guidance when that’s appropriate. One of the hardest things about this, Carolyn’s absolutely right, there’s no clear thresholds. You can’t say this happens at 5,000 people and this happens at 4,999, but a lot of the solutions we know individuals are going to come up with are going to be along a gradient. So for example, we have teens home now from school because schools have been closed. Do we allow them to get together with their friends? The best answer would be no. We might get some rebellion and some pushback from those teens. If we are going to allow them to get together, we can make that as small a group as possible.

Alison Buttenheim:

This is going to sound weird, but better for them to hang out with kids they usually hang out with already than to be in a group with mixed kids that they don’t usually hang out with. We want to sort of keep social contact as narrow as possible. Get together outside or in a house instead of being in a busy mall or coffee shop. Obviously don’t pass the phone around, don’t share drinks. All those rules are still in place as well. And we know that people aren’t going to be able to flip a switch and suddenly just be at home all the time, never leave, with their whole families, but we want to encourage people to make decisions along the gradient that’s as close to that complete social distancing as possible.

Carolyn Cannuscio:

I love that you brought up that issue and I like the way you’re thinking about it, Alison, and I think my own adolescents would appreciate your ideas. I would say that some families can band together in a pack, that those two families, for example, will socialize together but will otherwise limit their contacts outside the home. That might be a way to increase social support and ability to cope during this incredibly stressful time. That is the irony of an outbreak. It is a time when we desperately need our loved ones and we need social support, but we are most helped or best served from a community health perspective if we limit those in-person social interactions. One of the other things I’m wondering about is, what are some creative ideas you have about virtual interactions and how to increase that social support virtually?

Alison Buttenheim:

Well, I overheard about three hours of that last night in my house from the third floor. I think a group of four or five of my daughter’s friends were on some dumb video chat platform, I don’t even know what it was, for a very long time. And the upside is teens are used to interacting this way. That’s not much different from what would normally be happening on a Wednesday night at my house. But they have those routines in place to still get interaction with their friends.

Angelarosa DiDonato:

Yeah, I think that might be the one advantage to this generation that usually is all on their phones anyway.

Carolyn Cannuscio:

I would say that my teenagers are recognizing how much they long for not just in-person contact with their friends, but I’ve had them home from school this week and they really missed school, so that’s a surprise. And I would also say that my younger children, I have two younger children and two older children, and my younger children are quite flexible and resilient. So I am looking to some of their playfulness and their ability to make up new games and call my mother who is isolating herself at home and play those games with her over the phone or to have a ritual of listening to the same uplifting song every night. These little things, I think we can try to plan into our day some respites from the stress of thinking about this crisis.

Alison Buttenheim:

One of my strategies with my family for the next several days is going to be digging into a very large pile of board games that Carolyn actually gave me for my 50th birthday that has just been waiting for this kind of cocooning, social distancing crisis to discover. Silver linings are a little tough to find right now, but our family, we have a kid home from college who’s now stuck here for two extra weeks, at least, past when she was supposed to go back to school. And we have the high schooler home and I’m really trying to look for the joy and the unique opportunity for the four of us to hunker down with books and games and videos and doing some cooking with groceries that we buy at low-volume times at the grocery store. There’s some glimmers of silver lining here.

Angelarosa DiDonato:

Yeah, they’re all great things. Alison, I’ll start with you first. How do you think that this is going to play out over the next couple of weeks and how long do you anticipate this peak effect of this to last?

Alison Buttenheim:

I would love to have a crystal ball on that question, and I think anyone who says they can project out much more than two to four weeks is wrong. I had a colleague yesterday at Penn, Scott Halpern, describe it this way. He said, "In the 95% confidence interval of what things look like in two weeks includes we’re back to normal and no one is leaving their homes and it looks like Italy." I mean, that’s the wide range of even where we might be in two weeks. Again, I’ve had a lot of inbound questions. What about this trip? What about this cruise? What about this event that I’m supposed to go to? And I think it’s fairly easy to say cancel everything in the next 60 to 90 days. Even if things are more back to normal sooner than that, I just think we can give ourselves slack and buffer by not worrying about when do we have to decide about the event that’s 68 days away from now. The other really important point is, what things look like in two weeks or two months depends on what we do today. It’s not like we have to sort of wait and see what happens. We can take action now, especially around the social distancing, so that two weeks from now things look better than they would have if we hadn’t done those things.

Carolyn Cannuscio:

I totally agree. I would say to any person who feels afraid right now, and I know there are many, many people who feel afraid right now, take that fear and turn it into a positive action. This is truly a time when every single thing we do matters for the health of our community, for the wellbeing of our healthcare workers, for the basic functioning of our healthcare system, and we each hold so much power to flatten the curve, to limit the number of new cases. I also want to say that it’s very easy for us to think of ourselves as individuals and it’s very difficult and abstract for us to think at a population level. And so as people are asking, "Should I go on spring break?", if your decision were truly the decision of just one individual, the answer to that question might be different, but imagine that many, many households are thinking right now, "Should I travel or should I stay home?" Please remember that the migration of people is fuel for an epidemic. During the 1918 flu, we had troops moving across the country, and that troop movement was an incredible source of transmission of the flu. And the same will happen here if we all decide that we’re going to just keep our trip because we’re so stressed out that we need a reprieve. So try to think about the collective good right now.

Carolyn Cannuscio:

The other thing is, we hear a lot of people saying, and I’ve heard this from students and I’ve heard it from fellow middle-aged folk who have said, "What really happens? It’s not that serious of disease, right? It only affects older people and people who are already sick." To that I would say we have 133 million people in the United States who are chronically ill and we have so many elders who we all love and adore and want to be here for our own children so that our children have grandparents and parents, and try in making these decisions to think about those beloved people and act in the way that will protect them. Try to focus on one person you know and care about who is older, who maybe is immune suppressed or who is going through chemotherapy or who’s very old. How would you want others to behave to protect that person? Make that conservative decision about your own behavior on behalf of someone else. We’re calling upon everyone to be generous right now and to think about the vulnerable and to think about the collective good.

Angelarosa DiDonato:

I think that is fantastic advice, and I feel like this is a perfect place to end. I thank you both for your time and your dedication to getting the word out on what’s going on with this epidemic. I’ve been following you on social media this week as me and Marion were having this conversation and you’re putting great information out there and you’re really helping people make better decisions. So I applaud you for that and I appreciate your work.

Alison Buttenheim:

Thank you so much, Angela.

Carolyn Cannuscio:

Thank you.

Angelarosa DiDonato:

Amplify Nursing is hosted by Dr. Angelarosa DiDonato, and Marion Leary and produced by the University of Pennsylvania School of Nursing, with special thanks to our Department of Information Technology Services for their assistance. Music for the podcast was created by Harper Leary. The podcast is made possible by the Krista and Rich Pinola Fund for Innovation in Nursing.

Marion Leary:

Follow us on Twitter at Penn Nursing. Until next time, keep pushing over under, around, and through.