SCCM Resource Library-Public Health Crises: From Measles to COVID-19

Video Transcription

Ladies and gentlemen, please welcome Dr. Ed Conway. Good morning. It's my pleasure to introduce this morning's plenary speaker, Dr. Howard Zucker, who will  present this year's Aki Grevnik Honorary Lecture. Dr. Zucker is the Commissioner of Health for New York State.  As the state's chief physician, he leads the Department of Health's public health initiatives and oversees its healthcare workforce and healthcare facilities.  He's been working with Governor Cuomo to manage New York State's response to the COVID-19 pandemic, and has also worked at the helm on such critical illnesses as the 2018-2019  measles outbreak, vaping-related illness, Legionella, the Zika virus, Ebola, and medical marijuana.  Dr. Zucker trained in pediatrics at Johns Hopkins, in anesthesiology at the University of Pennsylvania, pediatric critical care and pediatric anesthesiology at the Children's  Hospital of Philadelphia, and in pediatric cardiology at Boston Children's Hospital. He's board certified in six specialties and has held academic appointments at Yale, Columbia,  and Einstein Medical Schools, at Georgetown Law, and on the NIH faculty. Dr. Zucker served as a White House Fellow, HHS Deputy Assistant Secretary of Health,  Assistant Director General of the World Health Organization, and an Institute of Politics Fellow at Harvard Kennedy School.  He holds a Bachelor of Science degree from McGill University, an MD from George Washington University, a JD from Fordham University, and an LLM from Columbia University.  Please join me in welcoming Dr. Zucker as he presents the Aki Grevnik Honorary Lecture titled Public Health Crises from Measles to COVID-19.  It is an honor to speak at this year's Critical Care Congress and to give the honorary Dr. Grenvick Lecture.  It is also an honor to have met one of the founders of the Society of Critical Care Medicine, Dr. Aki Grenvick, a true pioneer in this field.  Today I'd like to talk about risk in public health, and I'll begin at a place you might not expect, so indulge me, buying a new car seat for my growing toddler last summer.  Given that I was also fighting a global pandemic in New York State at the time, I had to just try to pull myself away as this was an important task.  I was struck by the stark contrast between the many layers of government safety regulations for transporting children today and my own history as a kid in the backseat of a car.  The New York State Department of Motor Vehicles requires safety seats and child restraint systems to be certified according to the Federal Motor Vehicle Safety Standard 213.  And the Governor's Traffic Safety Committee, of which I'm a member, regularly offers safety seat fitting stations across New York.  Now compare that with getting into our family Lincoln with no seatbelt and bopping about like a pinball during an hour's drive.  It wasn't that my father, a pediatrician, and my mother were lax parents at all. It was just the culture we shared. Out the window, motorcyclists without helmets.  In other cars, parents chain-smoking in the front seat with kids in the backseat, wrestling without seatbelts.  Merging onto highways, cars were driven with people who surely had too much to drink. Airbags, airbags, they were unheard of.  Now risk has always been a relative term in American life. It has shown itself to be fluid even when it comes to public health.  Risk is something that we in critical care live with every day. It is actually inherent to what we do.  When I began my career, Dr. Pina Templeton, Pediatric Anesthesiologist at the Children's Hospital of Philadelphia, told me something I never forgot. I was a medical student.  I was on rotation with a desire to do anesthesia and pediatric critical care. And Pina said, for you to succeed in this field, you need to be able to make decisions  without all the information and manage risk. I never forgot those words. They have been applied to my entire career and never more so than during this pandemic.  The 1918 influenza pandemic went on for nearly three years, killed 675,000 Americans and 50 million people globally. Most believe it ended with a mutation to a less lethal strain.  Now we didn't actually beat it. We just outlived it. You can't actually beat Mother Nature. Now other highly contagious diseases lingered throughout the 20th century.  The search for a polio vaccine took decades. Measles was a killer of children for half a century before a vaccine became available.  For most of the 20th century, we lived with public health risks that today seem shocking. My father, the pediatrician driving that Lincoln, was a medical student in Boston at  the time of the 1942 Coconut Grove nightclub fire, and he went to the scene where 492 people died. The scale of tragedy shocked a nation already at war.  But the fire was the catalyst for significant changes to U.S. safety standards. Other tragedies that caused us to take action against needless risk to public health, like  doctors going from one patient to the next without washing their hands, manufacturing wallpaper with arsenic and cough syrup with cocaine, promoting smoking as a good way to  lose weight. But the pace of this progress became supercharged in the early 1960s, thanks to scientific discovery and public health and anti-poverty measures.  Since the 1960s, America has made great progress on laws about smoking and helmets and seatbelts and drunk driving.  Americans will change their attitudes towards risk if you give them the facts, explain the science and back it up with better outcomes. Or so we thought until 2020.  For me, one of the most shocking aspects of the COVID-19 pandemic is how much risk Americans are willing to accept.  And during this unprecedented public health crisis, many citizens considered their right to crowd together more important than human life.  But then my experience as New York State Health Commissioner should have prepared me for this illogical tolerance of risk.  In the summer of 2019, I encountered another public health emergency, a months-long measles outbreak in the lower Hudson Valley.  It threatened to end the United States' 19-year measles elimination status. History teaches us that vaccines are victims of their own success.  Herd immunity makes infectious diseases invisible. People tend to forget how dangerous they actually are.  We have generations today who know nothing about the devastation of polio, measles, epiglottitis and pertussis.  In fact, if you ask most pediatric anesthesiology fellows about how many patients they intubated for epiglottitis, almost all would say none or one.  And yet when I was a fellow way back when, we saw many. But it was before the haemophilus influenza vaccine.  The New York measles outbreak was concentrated among Orthodox Jewish communities. They were traced to travelers returning from Israel and Ukraine, where measles is prevalent.  Over 1,060 New Yorkers were infected. The New York State Department of Health did everything right, rapidly mobilizing to help prevent secondary cases.  Under-vaccinated, close-knit communities became extremely vulnerable, despite an overall high rate of vaccination, and cases can rise quickly if you don't act fast.  At least 90-plus percent of the population needs to be vaccinated for measles herd immunity. With local partners, we administered nearly 85,000 MMR vaccinations.  We had the department staff working closely with local health departments for a year, forging relationships with communities based on mutual responsibility, trust and caring  for one another's children. Developing Yiddish-language publications to get messaging across. Working closely with a trusted health clinic, Refuah, to maximize touch points.  We launched a measles watch dashboard to provide timely information and locations offering MMR vaccinations.  Governor Cuomo signed legislation in June 2019 to eliminate non-medical exemptions for vaccinations required for public and private school attendance.  Our base-level rate of MMR vaccinations in the entire state before the outbreak was 96 percent of school-age children, however not in the affected communities.  We improved those areas by 11 percent. Our experience taught us that data transparency and trust are essential.  In October 2019, the department marked the passage of two incubation periods without any new cases, and it happened just days shy of a year from the outbreak onset.  This declaration meant that the United States maintained our coveted measles elimination status. The question is, how did we get to the brink of risk when doing everything right?  As we fought the outbreak, the vulnerability caused by vaccine hesitancy in New York's Orthodox communities was exploited by the anti-vaccination movement.  We were seeing, in real time, our steadfast work over nearly a year dangerously obstructed by this loose conglomerate of anti-science zealots.  We knew this movement specifically targets misinformation at racial. We knew this movement specifically targets misinformation at racial, ethnic, religious, and cultural groups.  In 2017, it went after the Somalia immigrant community in Minnesota, essentially generating a measles epidemic.  And in 2018-2019, it immediately seized on the New York cases to go after the Orthodox Jewish community using inflammatory language.  Now while we were fighting these Orthodox community outbreaks, anti-vaccine groups were emboldened to stage rallies to make inroads into other ethnic communities.  We learned that anti-vaccination propaganda and misinformation is more effective when there is a void of public health literacy.  As a nation, we dropped the ball on public health information. How? By assuming that once the case for vaccines had been effectively made in the past, we  didn't need to continue telling Americans why. But if we want to vaccinate every child against 14 dangerous diseases in the first two years  of life, we need to explain to parents the need. At first, political stances against vaccination and other public health initiatives were motivated  by an aversion to government overreach. But soon, mandatory vaccination became the subject of conspiracy theories.  It wasn't simply that government was trying to tell you what to do, but that it was actively trying to cause you harm.  Mix these conspiracy theories with social media's exponential spread of misinformation, and you have a serious problem.  So did the measles outbreak help my department with what was to come later on? Yes. New York's experience with measles got the department asking important questions that  are the very ones we grapple with right now in response to COVID-19. What had been an anti-vaccine movement in 2019 quickly transformed into a full-on anti-science movement in 2020.  Many Americans called COVID-19 a hoax perpetuated for political reasons. There was a proliferation of conspiracy theories about the intentional release of a SARS-CoV-2  by any number of villains. Distrust in government public health initiatives morphed into distrust for all institutions of expertise, medical, scientific, economic. The result?  As we approach the year anniversary of this pandemic, there is nearly a half a million deaths. In other words, risk has run rampant.  Those in the field of critical care medicine must make decisions without information. You must make life or death decisions when you don't have the facts, and you must sit  comfortably with the unknowns. By profession, you must live with risk so that the public doesn't have to live with a risk.  The last thing you want is a public that is risk-complacent versus risk-averse. We make decisions all the time.  Operate, don't operate, intubate, extubate, ECMO, LVAD, everyone is fraught with risk. But we use the knowledge we have, the experience we gained, and the collaborative team spirit  to do what we believe is based on science. Where did this risk-complacency come from in other areas of society?  Let's go back for a minute to the early 1960s, when as I mentioned, U.S. public health started to get a handle on risk. What was happening then?  The Salk polio vaccine had been enormously successful since it was licensed in 1955. Following a mass immunization campaign by the March of Dimes, the annual number of polio  cases fell from 35,000 in 1953 to 5,600 by 1957. By 1961, only 161 cases were recorded in the entire United States. And in 1963, the Enders-Measles vaccine was licensed.  What happened in the early 1960s that was good for public health? A Pew Research Center paper looking at public trust in government between 1958 and 2015 provides an important clue.  In 1958, the American National Election Study asked, how often do you trust the federal government to do what is right?  The percentage saying they could trust the federal government to do the right thing nearly always or most of the time reached an all-time high, 77% in 1964.  Within a decade, the trust had fallen to 36%. By the end of the 1970s, it was 25% that felt that they could trust the government most of the time.  And since 2007, fewer than 3 in 10 Americans have expressed trust in the federal government in every major national poll.  This trust has been decreasing throughout most of our lives. By 2014, studies showed that parental confidence in authorities like the CDC and in pediatricians  was dropping, especially around vaccines. Mistrust in government is a contagion. It spreads silently, much like COVID is now spreading within people's living rooms.  It also poses collateral damage because when you remove public faith in government, you remove faith in or concern for communities.  When people don't care about their own communities, then you get to the place where they prioritize personal liberty over saving multiple lives.  They will put almost 48 million of our nation's seniors at risk to ensure that individuals  can exercise their right to gather in a crowded bar, restaurant, or other social place, knowing that they very well may bring the disease face to face with an elderly person.  We learned the hard way in 2020 that we were fighting an unprecedented threat to public health within a culture that showed a growing tendency to undermine public health.  When you consider this substantial challenge, New York State has done a phenomenal job. Our early spring surge was unlike anything seen around the world.  During the 72-hour peak between April 11th and 13th, 18,825 patients were in the hospital statewide, 5,225 in the ICU, and 4,494 intubated.  Our decisions in managing hospitalizations and viral spread among nearly 20 million residents prevented at least 100,000 dangerous infections.  Very often over the past 10 months, I have recited the key points of how to beat back COVID, the checklist. But they bear repeating.  Base all decisions on facts, data, and expert analysis. Establish, track, and enforce metrics for continued local and statewide safety.  Be fully transparent with the public, prioritizing clear communication and access to the most current statewide and county data.  Prioritize testing and tracing, identify positive cases through diagnostic testing, aggressively trace and test the contacts of those who test positive.  Forge and maintain partnerships with neighboring states, non-profits, and academic institutions. Prepare for the worst-case scenario.  If a model says that you may need 140,000 hospital beds, you need a plan for getting to 140,000 hospital beds.  Acknowledge and clearly report when the information guiding decisions is no longer accurate and swiftly develop contingency strategies to move ahead.  Our experience with measles has taught us the importance of focusing on data and transparency  in maintaining public trust and buy-in, here through social distancing and mask wearing, for the long haul of this pandemic.  And especially with COVID-19 vaccines, we understand that we will get nowhere without public trust.  Since we flattened the spring curve, New York continues to do better than most states in keeping infections from spreading.  We managed to hold the line against a January spike in cases because of December gatherings. We remain aggressive at holding that line as we enter this more dangerous period of  viral transmission with the B.1.1.7 COVID variant. We have three COVID-19 goals right now, building hospital capacity with the surge and flex  protocol for load balancing across all hospital systems, stopping the spread with increasing  testing and specific restrictions in areas with high infection rates, and getting needles into the arms of New Yorkers as quickly and as equitably as the federal government can  supply vaccine. New York State has been fortunate to be advised by three independent vaccine task forces,  the COVID-19 Vaccine Clinical Advisory Task Force, the COVID-19 Vaccine Distribution and Implementation Task Force, and the New York State Vaccine Equity Task Force.  With continuing shipments of allotted Pfizer and Moderna vaccines, the Department is working fast to vaccinate the 15.4 million eligible New Yorkers over age 16.  Phase 1A and 1B of our prioritized program encompasses 7.1 million eligible New Yorkers. We have completed vaccinations for all eligible nursing home residents and staff in Phase  1A and are getting close to 100% of healthcare workers. We currently have 1,200 vaccine distribution sites, but are still very early on.  As we continue to do everything to stop spread, we are working to convince New Yorkers to take a COVID-19 vaccine. We need between 70% and 90% of the population vaccinated.  You can quibble with the percentages, but the hardest part is achieving a critical mass of confidence early on.  A mid-December survey from the Kaiser Family Foundation found an increase in the share of the public saying they would get a vaccine for COVID-19 if it was determined to be safe  by scientists and available for free for everyone who wanted it. This percentage now stands at 71%, up from 63% in a September survey.  It is critical that we get out the message that the approved COVID-19 vaccines are safe, effective and equitable.  With Operation Warp Speed, the United States has shown the world that we still have the scientific know-how.  We produced two highly effective vaccines in nine months, and that is stupendous. And now every health department in the country must work together to build back trust in  government and institutions. Only by re-establishing public trust can we get back to the point where Americans will refrain from risky behavior that undermines public health.  Government and public health need to be twice as effective today as they were in 1964, because  we must counter outlandish conspiracy theories without repeating or reinforcing their claims. With facts and metrics, with transparency, and with being honest about our mistakes,  we can flatten the COVID outbreak curve. We can create a spike in the public trust curve, bringing it back to its pinnacle of 57 years ago. And we can go even higher.  We can do what we in critical care have always known, that critical thinking based on data can help us make the best decisions and appropriately analyze risk.  Every ICU doctor has it in their DNA to act in that manner. We need to impart that wisdom from our innate behavior onto others so that this pandemic ends as soon as possible.  Life support for a society is no different than life support for a patient in the ICU.  It requires the work of many and the knowledge to know when to add interventions, be it inotropes  or mechanical support in the ICU, or testing and tracing, zone closures, etc., in a pandemic. And when to remove therapies, weaning the ventilator, decreasing the sedation in the  ICU, or opening schools and restarting the economy in a pandemic. I've drawn from all my experiences from the past four decades of medicine and have applied  it to my role as the Commissioner of Health during these remarkable days. I ask you to help me so that we as a village together can achieve a better tomorrow. Thank you.

Video Summary

In his Aki Grenvik Honorary Lecture titled "Public Health Crises from Measles to COVID-19," Dr. Howard Zucker, Commissioner of Health for New York State, discusses the concept of risk in public health. He reflects on his own experiences during the COVID-19 pandemic and the measles outbreak in New York in 2019. Dr. Zucker emphasizes the importance of trust and transparency in maintaining public health initiatives and combating vaccine hesitancy. He also discusses the decline of public trust in government and institutions over the years, leading to a greater tolerance for risk. Dr. Zucker stresses the need for clear communication, data-driven decision making, and collaboration in managing public health crises. He concludes by highlighting the importance of building public trust and confidence in the COVID-19 vaccine to successfully combat the pandemic. Dr. Zucker urges society to prioritize public health and make informed decisions to protect lives.

Asset Subtitle

Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Identify government and public health directives and policies that have proved effective at managing dangerous spikes in hospitalizations and controlling community spread of infection during New York State’s response to recent measles and COVID-19 outbreaks
Identify the serious threat posed by both targeted misinformation campaigns and public health illiteracy, during both public health crises and “normal” times
Identify what federal, state, and local health departments can do to prepare for the next pandemic based on New York State’s experience—lessons from what we got right and what we were unable to stop from going wrong elsewhere in the country

Ake Grenvik Honorary Lecture

Howard A. Zucker

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Education

Year 2021

Keywords

Public Health Crises

Measles

COVID-19

Risk

Trust

Transparency

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