Infectious Diseases Expert Rishi Desai, M.D. on the Range of Possible COVID-19 Scenarios
Rishi Desai, M.D. is an Oakland, California-based pediatric infectious disease specialist, and the chief medical officer of the Salt Lake City-based Osmosis, a company that describes itself on its website as “a comprehensive platform that helps people around the world understand health more thoroughly,” through offering educational resources to both the healthcare professional and consumer audiences. Dr. Desai created something of a media sensation on Wednesday, April 1, when he gave an interview to Fox News host Martha MacCallum, and made it very clear that, in his view, as long as some stay-at-home and business shutdown orders remain voluntary, the nationwide rate of COVID-19 infections will continue to grow dramatically—a viewpoint that has not often been articulated on that network. That single interview gained him 36,000 new followers on YouTube in just 24 hours.
On Friday, Dr. Desai, who continues to practice as an infectious diseases specialist, via telehealth, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding what the leaders of patient care organizations can and should be thinking and doing during the COVID-19 pandemic. Below are excerpts from their interview.
What should the leaders of patient care organizations be thinking about, and doing, right now?
There are few moments like this where how a healthcare leader or patient care organization acts, will be remembered for a long time. And the thing that healthcare workers will remember is, did they have my back? Did they provide me with PPE [personal protective equipment]? Did they provide adequate testing at my hospital? And that’s what all patient care organizations need to be working on. And the needs will shift over time, from N-95s to ventilators to ECHMO. So what will matter most is how leaders are responding.
How would you frame how hospital senior executives are having to think about this situation, along several dimensions, including from clinical management, operational management, and financial management perspectives?
The key is first to think about the lives of patients, family members, and clinicians. And the second is the economic ramifications. In the first category, there are a lot of low-expense things they can do. I’ll make this slightly personal My uncle was admitted to a hospital for COVID-19. And his wife, my aunt, is unable to see him in the hospital, as they’re not allowing visitors. But had they provided iPads, that’s a low-tech, low-cost way to show caring for families. And in terms of finances, one element is getting more help, more people, out to health care systems. And if you can say to a nurse, we’ll bring in more nurses, nursing students, and others,, to assist you, that nurse will feel you have their back. Those nursing students can be trained quickly to help. So there are a lot of solutions out there that can mitigate some of the pain that wouldn’t necessarily be high-cost.
What kinds of things might we be able to learn from some of the challenges and failures in the healthcare systems of Italy and Spain?
I used to work at the CDC [Centers for Disease Control and Prevention], and did viral disease outbreak research, and that allowed me to go to other countries. I’ve practiced medicine in settings you’ve described, where we didn’t have enough beds, and people were lying on coats on the floor and we didn’t have enough ventilators, and children were allowed to die. Every day matters. Every day when we’re pointing fingers at each other, means lives lost. Every day where we’re coming together, lives are saved. We need to learn from Spain and Italy, and not blame, but grab onto solutions.
One of the things that was widely reported was that initial infection management and initial stay-at-home orders, came late in Italy and Spain. Do you have any thoughts on that?
I can’t speak to those specific situations, but timing matters. And every day that we don’t have actual isolation, leads to growth in the curve. And in terms of infection control, simple examples we can learn from. Sometimes, in an operating room, there can be positive pressure, and air can be being pushed out of the room. Now with COVID-, you typically want negative pressure. But imagine a patient has belly pain, and you say, maybe they should go to the OR; that’s the last place they should go if they have COVID-19, because now you’ve just infected the whole OR.
Do we need a comprehensive federal stay-at-home order?
Yes, absolutely, we definitely need it today, because every day on which it doesn’t happen, is a lost opportunity.
If the federal order were put in place today, how long would it need to last?
Well, and it depends whether it was enforced or not. I think the enforcement part is critical. If you told me today that today, we had a federal mandate and it was enforced, I would jump for joy. And I would say, we would have to watch for two weeks, and I would expect that within two weeks, the curve would start to shift. The ERs would start seeing fewer new cases. And the reason for the two-week delay is that that’s the average length of time from when you start to see symptoms and the symptoms worsen. And we’d have to wait for that number to go down dramatically to feel safe. But what’s exciting is that we have serologic data. We could do widespread immune testing today. And we could say, Rishi is immune, he could exit isolation, and maybe some healthcare providers who are immune could do high-risk procedures; and immune people could start up jobs, and that would help kickstart the economy.
What will the landscape around the pandemic look like in the next few months?
I don’t expect that anyone will release a mandate unless we see improvement. And at the moment, we don’t have reliable testing data, and now, the testing is being done by private industries, so there’s no federal aggregation. So I don’t think that we’re going to have a clear sense on the reliability for some time; I think the number of cases could rise for some time; but the notion that states will lift their mandates is not well-founded, unless we see improvement. The immune certificates would be one strategy to let some people out. Or maybe we could open up some counties and not others, so you might do regional changes, and that would open up businesses and also hope. People would feel hopeful, and people could rally around that.
And in states as big as California, you’ll see differences?
Yes, and rural regions, naturally, you have more social distancing. So you may not have the same crisis. The flipside is that rural areas generally don’t have the same access to healthcare. Also, there are whole industries to think about, like agriculture; we might need to open up certain industries.
Even if rural hospitals are only hit by a small number of cases, the impact on them could be devastating, correct?
The World Health Organization published literature around clustering, a whole operational strategy. Let’s say I run a small rural hospital, and I send a patient to the regional COVID-19 hospital. And let’s say I’m the infectious diseases doctor, I help triage them through telemedicine a lot of the expertise you would need. Also, we have to remember that it’s not like that hospital was empty; up to that day, that hospital was seeing diabetes, CHF [congestive heart failure], emphysema, etc. And so we need to figure out operationally, and the WHO has a playbook on this already developed.
Telehealth is really helping tremendously right now in terms of healthcare delivery during the pandemic, correct?
From my experience as a telemedicine provider, it’s very helpful that I’m boarded in California, but can see patients now in Arizona and Nevada. I’m overwhelmed with the same questions. If you imagine my day as eight hours with 32 people in a day, based on 15 visits. For me to see 32 people, that’s not the right scale we need for this. It helps. But we literally have millions of people who are the worried well, and you can’t just do that with 15-minute visits. You need to scale education. Osmosis is all about that problem. We’ve really applied ourselves to creating osmosis.org/covid19. Believe me, if you spend ten minutes on our website, you’ll get more out of that than spending ten minutes with me. It’s very pithy and to the point and engaging. Telemedicine is a good part of the solution, but there’s this massive other part.
What are your thoughts on everyone wearing some form of mask?
It’s a great question, and it will come up constantly in the next few days. This question is massive right now. There is data emerging that we can pass this through conversation. I can be asymptomatic or pre-symptomatic, and can pass this to you. That’s not yet in the general consciousness. But it makes sense, and we now have proof that it’s happening. Second, we’ve focused on six fee of social distancing, and my son is three years old, and understands that. But the fact is that some of that is based on outdated science. MIT scientists are reporting that a cough or sneeze can be propelled 27 feet. So where does that leave us with masks? Anything that keeps something close to your face, is helpful. I’m not looking at this as a perfect solution, but having everybody wear a masks is part of the solution. And the other part is keeping people in their houses. The challenge is, why are people going out in the first place? Make it a short trip. These are solutions that keep people from getting sick. If you have to go out, everybody wear masks.
Long-term confinement is a social problem, then, correct?
At our core, we’re mammals, and we need to be outside. We need to experience the sun and the wind and the earth. So you’re outside jogging in the late evenings, for example; we need strategic ideas on how we can fulfill these basic needs, while balancing them against risk. It will be things like you’re saying: do it early in the morning or late at night. Find a hiking trail where the likelihood of running through
Could you share your perspective on your Fox News interview, and what happened afterwards?
The person and team who invited me, were kind, courteous, and respectful. That’s the feeling I was left with. I felt honored to be on the show, and the host was 100-percent classy, and was treated very well. In terms of the audience, the audience that watches Fox news gets to hear about COVID-19 through interviews like the one that I did. And COVID-19 continues to be confusing to a lot of people. There are confusing new pieces of information dropping every day. And the more we can get all people up to speed on the facts, the faster, the better, because we can then essentially talk on a level playing field. And I’m certain some people might disagree with me on ideas, but at least we can agree on the facts. That’s why it’s important to speak on Fox. Based on my interview, that was a good experience.
What do you think the world will look like three months from now?
That’s a great question. If I knew the answer to that, I’d be very wealthy. I’m not a soothsayer or a futurist. But it is likely that what is happening in NY will unfold in other states; and that areas where the numbers have felt low, will increase the testing, and they’ll realize they’re much higher than they thought; and it’s likely that we’ll need more front-line healthcare workers and resources. And those are things we’re gifted as a country to do. We have resources. We have a well-educated populace and we have the Internet. We have publications like yours that do a good job of getting the information out there. We have to realize that time equals lives, and every day makes a difference. And there’s this whole idea about raising healthcare capacity. And at Osmosis, we’re trying to get people trained up quickly for free, to help. And we know that millions of people will lose their jobs before all this is over. We also know that HC needed more workers even before this. So there are opportunities here to take problems like unemployment and turn them into solutions, like getting more health aides and home health aides. And three months ago, if we don’t do those things, we’ll wonder why we didn’t.
Is there anything that you’d like to add?
As I mentioned, I’m the CMO at Osmosis. And why? We’re here to create the best possible learning experience for caretakers and clinicians; and never has there been this level of need. A lot of patients at home are being taken care of by family members; and that will be true here but also around the world. And the data is coming in every day and is overwhelming. Your part of the solution is to amplify information; our part of the solution is to get information out there. And you mentioned people who don’t think this is real; point them to our website. There’s nothing objectionable there. And in addition to education, there’s training. We know the economy will be reeling. And we know that HC is one of the fastest-growing industries, and that was true before COVID-19. So we’re training people for free, to get them into this. So we’re doing the teaching and training. That’s why I do this every day.
