Courtesy of SSM Health
Dr. Alex Garza
Dr. Alex Garza talks about life B.C. and A.C.—before coronavirus and after coronavirus—when describing his job. The chief medical officer of SSM Health, he says his job B.C. was mostly administrative, ensuring standards of safety and quality. But since the beginning of March, his work has shifted to focus 100 percent on the novel coronavirus. In January, he put together a small team at SSM to monitor COVID-19 in China and communicate with the Centers for Disease Control and Prevention. “After we felt confident that this was not going to be contained in China—once there were outbreaks in Iran, Italy, all of those other places—we pulled together a team of infection preventionists, facilities managers, emergency managers, and our supply chain people to get everybody on the same page,” he says.
Since he was named incident commander of the St. Louis Metropolitan Pandemic Task Force in early April, Garza is helping coordinate patient care and supplies among the region’s four major hospital systems: BJC HealthCare, Mercy, SSM Health, and St. Luke’s Hospital. Each day, he hosts a briefing on Facebook in which he details the number of hospitalized COVID-19 patients, the number in ICU, and the number of ventilators in use. Those numbers are expected to keep increasing for now—as of April 20, St. Louis was still on the ascending side of the curve of positive cases, with 757 patients currently hospitalized. The city reported 882 cases, and the county recorded 2,288 cases.
There might not be a better person for the job. Garza, a colonel with 20-plus years of service in the Army Reserves, was once chief medical officer for the Department of Homeland Security. His job was, in part, to evaluate infectious agents’ threat to national security, and he led the country’s response to H1N1.
In 2015, St. Louis Magazine interviewed you, and you posited: “We saw the spread of H1N1 throughout the world in a matter of months—what if it had been a deadlier virus?” Are we living out that hypothetical now? Is COVID-19 along the lines of what you were thinking?
It’s close. When I was working with the Department of Homeland Security, we did a lot of planning for pandemic scenarios. The one that we always worried about is what’s called Highly Pathogenic Asian Avian Influenza—the H5N1 scenario. If that ever became transmissible from human to human, it could be like the 1918 pandemic all over again. Nobody has immunity, it has a high lethality, all of those bad things. If you think about a 3 percent case fatality rate and immense transmission, that’s really what I was thinking about.
I will say, though, that this is a really, really good surrogate for that, because it has all of those essential elements. It’s highly transmissible from human to human—it’s not as high as something like the measles, but it’s more transmissible than influenza. We don’t really know what the case fatality rate is right now because we don't know what the denominator is, but we know it’s worse than seasonal flu. And there is no immunity within the population, so everybody is susceptible. So that’s concerning. No, it’s not a totally worst-case scenario, but it is a good example of what could happen if there was a pandemic of something like an H5N1.
Do you think, as we become an increasingly global city, we’ll change how we prepare for pandemics post-COVID-19?
As health care systems, I think we will take a different approach to preparing for pandemics, but recognizing that it’s really difficult to be 100 percent prepared for everything that comes down the pike. For example, we have this warehouse with personal protective equipment that we built for a surge of patients, and we burned through that really quickly in the initial phases of COVID.
You have to think about this almost as a multiphase strategy. We have to have some sort of stockpile to get through that first phase. But then there has to be a sequence of things that happen in order to get you through those next phases. Those are things like the Strategic National Stockpile that can come in and help out, and then, manufacturing capacity to start backfilling. We’re playing catchup right now because not all of those things are in sync. The Strategic National Stockpile becomes depleted because this hit multiple places really hard. There's just not enough supplies. But then we also didn’t have the manufacturing capacity in order to backfill everything. So why is that? Well, the majority of stuff is made in China. When these pandemics come along, I don’t think it’s realistic to say that health care systems should be able to stand alone to take care of them. It has to be a much broader plan, and things have to work in sequence in order for us to take care of the surge.
A lot of St. Louisans—for good reason, because we’re all staying at home—don’t know firsthand what it’s like at the hospitals right now. What are you seeing and hearing when you visit clinicians?
One thing is that they are incredibly adaptive. If you have a problem, give it to them, and they will figure out a solution. Most of the people I’ve spoken with have sort of settled into this new normal. Early on, it was “What is this mysterious thing called COVID?” There was a lot of anxiety around that. There was all this concern about PPE, which is understandable. But they've taken care of COVID patients now, they've been in some of these high-risk environments, and it’s like they understand it now. It’s not as super-scary as it was before. It’s like, “OK, I’ve seen this, I have taken care of this, I know what to do. Let’s just get on with it.” There’s an incredible esprit de corps now.
What are some of the ways in which they’re adapting?
At Saint Louis University Hospital, they did this small thing, but it’s really cool:
If your whole goal is to limit exposure to the virus, what are some things that you can do to prevent yourself from being exposed more than you should be? If you’re in the ICU, you have a number of medications that you have to give. They’re in these IV pumps. Frequently, you have to go in and change those. What they did is they got a lot of extension tubing, and they pulled the machines out to the hallway, so they're able to close the door. It’s a longer path to get to the patient, but then if they have to change out the medication or readjust the drip rate, they don’t have to go into the patient’s room.
There has been a lot of coverage about how COVID-19 is impacting black St. Lousians more than white ones.
Guns, violence, and germs disproportionately affect the poor and vulnerable. A quote that I like to use to frame this is from President Obama. He said disasters have a way of pulling the curtain back on the festering problems that have always been there. This is no different. It really did pull back the curtain on the festering problem, which is social and economic inequality. And, in some ways, racism.
So absolutely it’s affecting those populations more than others. And the reason isn’t because the virus favors one race over the other. It doesn’t care. But what makes it riskier for those populations is because of the many things that have created all of those social inequities. People that have to live in crowded environments, such as these multifamily dwellings. A lot of dense living conditions. Poor wages, poor access to health care, poor access to good food, all of those things contribute to being at risk not just for COVID but also things like diabetes, heart disease, hypertension, which, incidentally, makes you higher risk for COVID.
When you’re thinking about what contributes to the health of an individual, when you really boil it down, the delivery of health care has minimal impact on the health of an individual.
How is that?
The majority of things that really impact the health of an individual are things like social circumstances, behavior, and physical environment. I tell a lot of people that I work with in health care that it’s really about defect management. Because there are other things that are impacting the health of an individual, and that’s your living situation: how much money you make, what is your social environment like, all of those other things.
When all those things impact the individual, then they show up at health care’s door. They’ve been smoking or they have a really poor diet or they have cardiovascular disease. We put you on medications or take you to the operating room, but until we get further upstream to stop things from happening in the first place, we’re just going to continue to do defect management. That means there have to be more broad, community, societal changes to fix those things. That’s a much bigger task than anything that we do with health care. It’s ensuring that people have a livable wage, they have affordable housing, they have good education, good food, access to health care, those things that we need to decide as a society.
How do we move forward and try to prevent this from happening again?
We sometimes use this quote: “Never let a good disaster go to waste.” One of my hopes of coming out of this is that we can make those societal changes that are going to be long-lasting instead of just dealing with the immediate problem, which is the pandemic. When people say, “Well, maybe we just need more stuff, a bigger stockpile.” Part of that is right. But the other part is, “How do you build resilience in the community?” And the only way to really do that is to ensure that there aren’t inequalities in the community, because then you don’t have these disproportionately affected groups that drive a lot of the morbidity and mortality. If everything was more equitable, we could face the pandemic from a much better place. We’d be much less vulnerable.
