During the course of the pandemic, medical centers spun out new treatment protocols on the fly. Now the institutions are racing to develop potential vaccines and therapeutics, and using big data to tailor their treatments to individual patients, physician leaders told The Hill during an online panel discussion Wednesday afternoon, sponsored by the the Association of American Medical Colleges.
Meanwhile, facilities are simultaneously grappling with supply shortages and racial disparities in health outcomes. Some have found innovative solutions to address the former, while resolving to remain committed to the latter.
SARS-CoV-2 is in fact a “novel” coronavirus, said Selwyn Vickers, MD, dean of the University of Alabama at Birmingham (UAB) School of Medicine. “Novel meant … creating our own road maps as we walked. We didn’t have drugs initially to treat it, we didn’t know all the organs that it damaged, and we didn’t know a great deal about its transmissibility and how robust it was,” he said.
Academic medical centers began designing their own treatment protocols because there was no textbook paradigm for managing the virus. Those protocols were then spread throughout a state and later the country, he said.
The vast expertise and resources of some academic medical centers helped them to weather certain supply shortages.
Carrie Byington, MD, executive vice president of University of California (UC) Health in Oakland, said her system has fought supply challenges throughout the pandemic, leveraging staff resources and technical skills.
When shortages struck, UC’s theater department began making face coverings, the biological laboratories came up with its own transfer media, and engineering departments used 3D printers to produce nasal swabs and ventilator parts, she said.
A robust supply chain is important, Byington said, but the institution was lucky to have creative faculty, students, and trainees to identify solutions.
In assessing the current status of vaccine research and therapeutic development, Paul Rothman, MD, dean of the medical faculty and CEO of Johns Hopkins Medicine in Baltimore, noted that there are around 180 different vaccines being tried.
One approach is to use either monoclonal antibodies or convalescent serum.
Johns Hopkins is part of a national trial using only sera that has antibodies either to help patients who are already sick with COVID-19 or to give to those who have been exposed “to see whether we can intervene” and prevent disease, he said.
As for the therapeutics, most are antivirals, Rothman said.
One lucky coincidence for Vickers was that UAB received a large grant 2 years ago and the number one project in that grant was the development of viral therapeutics for coronaviruses.
Vickers remembers laughing, “I said, ‘Who cares about coronaviruses?'”
That was then; what came out of that research was the drug remdesivir, he said.
Remdesivir, which was initially developed as an Ebola therapy, was found effective against COVID-19 in two randomized trials. Several other antivirals are in clinical trials now or will be soon, Rothman said.
Another important area of research is understanding ways to “help the body deal with” coronavirus, he said.
One part of that is looking at who needed to be ventilated and which patients did not, Rothman said.
Research on the long-term impacts of the virus is also critical. “What we’re starting to learn is, it’s not just a 2- or 3-week course for many people” — some patients may be sick for weeks or months, Rothman said. “So, understanding the normal disease course is going to be really important.”
Scientists at Johns Hopkins and other institutions, he said, are using big data to try to determine “who’s gonna get sick, who’s not gonna get sick, who’s gonna get sick for a long period of time? Who’s gonna recover?”
The goal is to answer these questions early “and try to intervene in any ways we can,” Rothman said.
As for vaccines, the pace of research there has been astounding, Rothman and UAB’s Vickers noted.
The timetable from identifying the virus, then sequencing its genome, and using novel molecular techniques to manufacture not dead viruses but reactive parts of living virus as the stimulus for the vaccine, “it’s pretty amazing,” Vickers said.
But his excitement is tempered by the overwhelming need in the public health sector.
One challenge area not only for academic health centers but also for health systems around the country has been the virus’s disproportionate impact on people of color.
Much has been written about high-profile medical centers and their dubious record of providing “community benefit,” which is a requirement of their tax-exempt status.
Asked how health systems have addressed socioeconomic disparities in health outcomes, Byington explained that as a land grant institution, UC Health has always been committed to serving all Californians. Virtual care allows her health system to reach communities that lack access to any academic health center or hospitals that have cared for ventilated patients in the past, she said, and the impacts of COVID-19 gave a big boost to virtual care and telehealth.
Before the pandemic, UC Health had less than 5,000 virtual care visits per month, but now across the system, those numbers have leapt to 200,000 visits each month.
“We’ve been able to share our expertise much more widely, across the state of California; in New York City, where we worked with individuals during the crisis there; on the Navajo nation; and across the southern border in Mexico,” she said.
One challenge for many academic medical centers has been that they have not taken time to build trust within their community, Vickers said.
Three-quarters of Birmingham residents are African American. “It’s hard in this scenario to get in the game of trust-building if you hadn’t done it already,” he said. Fortunately, UAB had already worked hard to establish trust prior to the pandemic, enabling Black people in the region to feel safe seeking COVID care.
But there were hiccups along the way: “Early on there was a thought that the virus really couldn’t infect Black people,” Vickers said.
So, UAB held a town hall on Facebook with over 120,000 participants, including pastors and community leaders, and helped to dispel that myth, he said.
His institution has continued to engage with those communities to promote coronavirus testing.
Four factors that put people at risk for the virus are primarily related to social determinants of health, Vickers said:
- Living in a high-density area
- Being an essential worker
- Using public transportation
- Having a chronic disease, such as heart failure, kidney disease, diabetes, or obesity
UAB continues to intervene around social, as well as medical, determinants of health, he said. Vickers recently co-authored an article in the American Journal of Medicine with Mona Fouad, MD, MPH, and John Ruffin, PhD, detailing steps that health systems can take to prevent the widening of health disparities, such as equitable testing and ensuring that minorities are represented in vaccine trials.
Vickers cautioned, though, that delivering acute COVID-19 care is not the end of the story. “There could be chronic problems for a long time, and so we have to look at managing them long-term,” he said.