Ngozi O. Ezike, MD, director of the Illinois Department of Public Health, discusses state and regional management of the COVID-19 pandemic. Recorded November 9, 2020.
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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA. And I'm thrilled to be joined by Ngozi Ezike, who's a pediatrician and an internist, like I am a pediatrician. And she's Director of the Illinois Department of Public Health. Ngozi, thank you for joining me today.
>> Ngozi Ezike: Thank you so much for having me, Dr. Bauchner.
>> Howard Bauchner: Oh, my Lord, call me Howard. My kids call me Dr. Bauchner. You should call me Howard.
>> Ngozi Ezike: Thank you.
>> Howard Bauchner: Ngozi, what's it been like?
>> Ngozi Ezike: It's been an incredible journey. On the one hand, I'm so thrilled and honored to be at the helm and watch my team just really soar, essentially, to heights that we probably didn't even imagine that we could in terms of the amount that we have stretched ourselves to try to meet the demands of our state. But it's also so saddening to think that, despite the Herculean efforts of the team, that that in itself is not enough to stave off what we're now looking at, which is so gloomy as we are numbering 10,000 new cases every day. And our hospitals are filling up again. And just seeing history replay itself is really painful.
>> Howard Bauchner: I think you know, I get a chance to interview a lot of people from around the country and around the world. And most of them are pretty removed from what's happening day-to-day. That's not true for you. You live this pandemic seven days a week, 24 hours a day. I can't thank you and the governor and the mayor of Chicago enough. I live in Chicago. The data from Illinois, up to the last couple days, have been outstanding. The sixth most populous state, but around 15 in deaths per 100,000. Congratulations. I know there's been 10,000 deaths, but there's some accomplishment, some enormous accomplishment in that. And I think Illinois has been one of those states that have really stayed the course. Now you're faced with five, or seven, or 10,000 cases a day. As you already mentioned, the hospitals are getting busier. Now, the good news is the death rate. The case fatality rate has really come down. The most recent data, even for seriously ill people, if you're not on a ventilator, is substantially under 10%. If you're on a ventilator, still around 35% or 40%. And as you know in many of the conversations I had, people were concerned about November, December, and January. What's the next couple weeks look like for the state, Ngozi? What's it look like for what the state needs to do?
>> Ngozi Ezike: Yeah, I think, I think we really have to hunker down. And I think that's the problem, because that message has been the same message for so long that the message is not being received any more. And I think that was the message at the beginning, when it was all pretty novel, as the virus was named. But now, we're hearing those same words, but we're not listening any more. So, we are trying, in terms of IDPH, to try to invigorate new messengers. Maybe coming from not IDPH, not official public health people, but maybe from hearing from a community member from your local area. Hearing from a doctor at the hospital you would need, whether it's a COVID illness or a flu illness or if it's a car accident victim, that you would be able to hear from a doctor that would be caring for you that there's concern that there won't be enough beds. We need to understand that, as we are counting off these awful statistics every day about the numbers of people who are reported now lost to COVID, that this means more people than the 10,000 won't be at that Thanksgiving table. And yet, the other holidays, we still stand to lose hundreds more. I don't think that's fully sinking in. I think some of it is the desire to believe in things that are a little bit more comforting than the message that we're bringing. And so, just finding the right messenger to share with people how critical these next couple of weeks are. Because as much as we know what we can do, if they're not implemented, the doom and the gloom will absolutely be our future. And it will be worse than what we saw in that first wave.
>> Howard Bauchner: Now, President-elect Biden announced the group of people who are going to advise him and offer direction. I was actually disappointed that more people like you weren't actually on the committee. Because as I said, you actually are dealing with the day-to-day issues. What is it that you want that committee to hear from you and the other 49 directors of public health for the states? Because the burden is on the states. What is it that you need to make progress around the pandemic?
>> Ngozi Ezike: No, I am very excited about the people. We have one of our own hometown heroes, Dr. Morita, a former Chicago health commissioner, so we're in great hands. All of those individuals are just stars. And so, many of them have that perspective. But I would just say as a state health official that we really, we would benefit so much from just having a unified strategy. It's not a tenable situation to have states being pitted against each other. Because one state is going in one direction, using the best information that they have. And then the neighboring state, which is literally across the street, is going a different direction. And then, people are forced to pick sides, and say who's doing it right and who's doing it wrong. We really want a top down strategy that will help us all be on a level playing field, so that different states aren't going through different waves at different times. So, as soon as you get something in control, your neighbors blow up, and then it comes right back through, you know, our borders. I think just that national strategy, and I'm confident we're going to get that, is really one of the key things to help us just level set be all oaring, you know rowing, in the same direction. So that we can get to the end of this pandemic together.
>> Howard Bauchner: Do you think we've finally reached the point where there is sufficient testing? Let's take out tracing and quarantine. I don't know if the country has the capacity to test, trace, and quarantine 100,000 people a day. That's a monumental task. But are you closer to testing than you've been in the past? Do you think there's adequate testing available? Or is it still not there?
>> Ngozi Ezike: I mean, I can speak for Illinois. I mean, we're one of the most robust testing states. We started to be the first state to have our public health lab do the tests on site. And we have just ramped this up. It was a dream to get to, you know, 100,000 a day. And we're just on the heels of that. So, I think we really have a good picture of what's going on. And the testing is not just localized in one part of the state. We have robust testing across the entire large, vast state. So, we have a great sense of what's going on. And with that, we can still, you know, increase resources in the places where we need to even test out a little bit further. You know, the rapid tests that are coming out are an additional resource that really help us to get quicker results in high risk areas like outbreak settings in correctional facilities or long-term care facilities. We're also piloting new ways to use it for schools and in manufacturing plants. So, I think we have great testing. But as the numbers of cases increase, and more people are identified as exposure contacts, the desire to get testing and the need for testing will only grow. So, I think we're in good shape now, but unfortunately, if the numbers don't turn around, the demand will grow as well.
>> Howard Bauchner: The epidemiology of the disease has actually been known since February when, you know, the leading journals published a number of epidemiologic articles. There's been some more details. But we know the high-risk groups. They have been very well-defined. And it's really based upon age and frailty. Obviously, that doesn't mean that people who are 20, 30, or 40 aren't at risk. But they're at much, much lower risk. Do you think the state has been able to provide the resources or insist that the resources are available to nursing homes and skilled nursing homes? Because you know the Illinois data. Also, of the first 100,000 deaths in the U.S., about 50% were in nursing homes and skilled nursing homes. Do you think you've been able to really insist that those environments be protected?
>> Ngozi Ezike: No, absolutely. They were top of mind even before we had the first identified case there. But still, some of the structural, say, weaknesses that already existed in that system really got, you know, that COVID light really shone brightly on it and kind of exacerbated, and it showed exactly all those weaknesses. I think we've tightened a lot of those things up with some emergency rules that we've put in place to make sure that testing happens on a routine basis, and then aggressive testing in the midst of surveillance to make sure, in the midst of an actual outbreak, to make sure that we keep testing until there are no more positive cases. You know, again, partnered with surveillance testing even in the absence of an outbreak. So, a lot of those measures have been strengthened. I know when I look very intently at the numbers of those who are succumbing to the virus to see, where are these deaths coming from. And before, there was a point where it was 60% of our deaths were long-term care. In the last month, if you look at the individuals over 65 that have passed, less than a third are from long-term care. Those other seniors are actually in the community and got it from community spread from, you know, younger people who are driving the infection now.
>> Howard Bauchner: Yeah, that root-cause analysis is always helpful, because at least it can show you where to, where to put additional resources. Now, you have national expertise in correctional facilities. And the death rates in correctional facilities has been incredibly high nationally. How has Illinois done around its correctional facilities?
>> Ngozi Ezike: So, we're still actively working. IDPH is working very closely with the Department of Corrections. Again, unless you've worked in corrections, sometimes it's hard to understand all of the additional challenges in terms of trying to isolate and quarantine people in the settings. It's not as easy as just saying, oh, you're positive. Move them here. Give a single room here. There are strong space constraints, and in terms, of how you can position people based on what they're there for. Again, it's very complicated. But we're working closely with the Department of Corrections, using both the rapid test and our, and our PCR molecular test to identify more routinely both staff, of course, and inmates that have been infected. And take the appropriate measures.
>> Howard Bauchner: Ngozi, sometime in the next three months, I'm hoping, someone's going to call you up and say, we have 500,000 vaccine doses to send you. Hopefully they won't, I've joked but I'm half-serious, some may have to come in a Good Humor truck, where they can freeze it. But at some point, in the next three months, I think at the state level, McKesson is the distributor. I know the Trump administration has hired the military to help with logistics. They're very good at it. Someone's going to call you up, or call up the governor and go, we have 500,000 doses of the vaccines. Have you began to think about what that may look like or feel like? Or how you distribute it? We know the first 20-million are going to healthcare workers. They will, that will be hospital-based. But the next 100-million are not going to be hospital-based. Have you begun to think about that?
>> Ngozi Ezike: Yeah, we have multiple teams that are involved. We have, of course, have our vaccination workgroup. But we're working hand-in-hand with our health equity workgroup just to make sure that we have that equity lens are we try to identify the populations and the neighborhoods and the parts of the state that have been hardest hit, that are the most vulnerable, that are the most susceptible to the worst outcomes, to be able to come up with a prioritization scheme within the prioritization scheme, in terms of getting this out. But even before we get to that, there's so much groundwork that we're trying to lay. Because some of the people who are in that most vulnerable of the vulnerable populations are also the most hesitant. And so, trying to work through some of the misinformation, some of the mistrust, that is the important groundwork that has to be laid by very credible messengers in the community, that can lay out what we know, what we don't know, and what the situation is with this vaccine. And what the options are in the absence of the vaccine. So that we can all make the best-informed choice. And hopefully make the choice to get a vaccine that's safe and effective to help end this pandemic.
>> Howard Bauchner: You mentioned this notion of states moving in different directions. You know, the Northeast, I think in February, March, and April, for New Jersey, Connecticut, and New York, really hunkered down. Obviously, in New York City, many people left the city. But New York has done quite well up to the recent few weeks. Vice President Biden, President-elect Biden, has talked about a national masking mandate. He has indicated that that's going to have to be driven by the states. I know that can't be easy for Governor Pritzker. What's your sense of that? If the numbers keep going up, you said we're at 10,000 or 12,000, up above 5000 almost now for two weeks. Is that where we're headed? And is that where the country needs to head, Ngozi?
>> Ngozi Ezike: I do think so. But it's easy for me to say that I think that that's the strategy-forward when I actually have my feet on the ground and I talk to people. It's not as easy as setting a mandate, and then thinking that it's going to, going to happen. I mean, I had a conversation with a woman yesterday that said, look, like this mask mandate, that's ridiculous. I mean, that's really, that's not even something you can do. And I said well, I think it's very akin to the seatbelt mandate.
>> Howard Bauchner: Right, that's been the analogy.
>> Ngozi Ezike: That's been in existence for such a long time. And she, she immediately came back, was like, well, we probably shouldn't have that, either come to think of it. And so, I mean, if we're going to be working with such a divided populous that's going to push back on some key but basic strategies, I still think it's going to be a war of winning over hearts, and saying that look, we want to save lives. And this is the way to do it. So, it's not as easy as putting a mandate out there. We've been talking about masks and saying that they have to be on for months. And I think we might be at 50%. And that's not going to get it. And we don't have enforcement, whether at the local level or the state level, to run around giving every citizen in the country a ticket. So, it really is incumbent on individuals to want to take this on. You know, I talk to my colleagues not only around the country, but around the world. And when I talk to my colleagues in Korea, they were like, it's just a, it's our cultural, it's within our cultural fabric that if we understand something that will help our community, we're all going to take it on. So, unfortunately, I don't think we have that as ingrained. We're more the rugged individualists. And as I keep saying, rugged individualism doesn't work in a pandemic. At all. And so, we're going to have to find a way to take on some parts of our culture that maybe aren't as strong and bring it in. That community, that sense of community and doing something for others that maybe is not just for my benefit, but might benefit others. And figuring out how to win people over to that new kind of thinking. I think that's where the challenge lies.
>> Howard Bauchner: Yeah, trying to normalize that behavior. I mean, we both have children. My kids would never get in a car and not put their seatbelt on. And, you know, they would be aghast if someone smoked in a restaurant. That behavior's all been normalized. And somehow, we haven't normalized masks.
>> Ngozi Ezike: It took time. It took time, right.
>> Howard Bauchner: We've actually made it political. It's exactly, it's exactly the opposite. And this tension about controlling the pandemic or the economy. You know, I've been fortunate enough to interview Tony Fauci numerous times. And Tony's trying to make the case repeatedly, they go hand-in-hand. If we can control the pandemic, the economy can reopen. But it's very hard to just reopen the economy without the pandemic being under control. And we know how to get there. We've proven it over and over again. Arizona's probably the best example. They had huge amounts of disease. They masked. And three weeks later, they're economy was open. So, it is doable. I have to ask you what has become a more complicated question. I've had many people on, and they've wondered if we've made a mistake with the schools. The most recent data suggests that schools are not the nexus for a lot of spread. That's not to say that teachers wouldn't be at risk if they were teaching. It wouldn't say that the very rare child may get disease. But there's been increasing concern that we really do need to try to move to a way in which we can open the schools. Even if it, even if it's a hybrid model where, you know, the third, fourth, and fifth graders are physically in school and perhaps junior high and high schoolers aren't. And in that model, you could use the space of the junior high and the high school for the younger grades so that people could spread out, which to me always seemed the rational approach. But it's complicated. I'm not a teacher. I'm not putting myself at risk. What's your sense on schools? It was interesting in the state of Massachusetts. The governor's been very clear. He wants the schools open physically. Can we get there this year, Ngozi?
>> Ngozi Ezike: No, I think what we need to understand first is that, I think we all agree that students need to be in person to learn. That that's how teachers were taught to teach. That's how students can best learn. I don't think anyone thinks that the ideal or that it's an equivalent to learn remotely. Especially our younger learners who are just kind of getting some of the basics, learning their social skills, and all the other services that are provided from within the schools. In the state of Illinois, we did not prescribe to any school, yes, you know, absolutely all full remote. We empowered all of the schools with all the information, all the tools, all the data that we had to say, this is what we need. We need to keep the kids distanced. We need to keep the kids masked. And the schools have been amazing partners. That's probably one of the safest places you could be in in terms of full adoption of masking. So, I absolutely think that, you know, we are continuing to want to get kids in school. I think it's an individual choice that a family could make to say, look, you know, maybe because of my specific situation where we have high-risk individuals at the home. Or, you know, I'm a teacher and I don't feel comfortable. Because, you know, I've worked with my own school district. You know, there are great plans in place. But as I was telling our superintendent, even with the best plans, of course we will still see cases. Of course, we will still see outbreaks. I mean, you have to socialize that with the parents and the teachers, that there's no 100% in this, in this, on this report card. But we can do the best we can. And I think schools have. I also see that schools are, you know, essential in a way. That you really do have to, you know, try to maybe close some other things to support schools. But you can't have everything open if it's not going to allow, you know, the disease to be controlled to a certain level. I say that as I'm seeing the numbers really skyrocket. And so, it gives everybody, you know, nervousness to continue being in that setting. It is hard to have a healthy school community in the set of a, in the center of a community that's on fire with the disease. And so, as, you know, even in my school and most parents that I know, they're getting letters everyday about, you know, new cases, new cases. So, just the disruption is much. But I still think, if we can just get everyone to do the masking and curtail some of the private gatherings, if we could turn the numbers around and decrease the level of disease and the transmission, the level of the disease, we could have, you know, stable settings for some of our students to get that in-person learning.
>> Howard Bauchner: I know there's been challenges. It's probably so long, I don't really want to go through it. But what have been the surprises, Ngozi? What, when you look back, would you say has been the three or four remarkable surprises, either good or bad, or challenging. But that you go, wow. I didn't think about that. Or wow, that's a surprise. Or, what would the surprises be?
>> Ngozi Ezike: Yeah, I think, I think we have been able to show that government can move quickly and make things happen. You know, we've had to act very quickly to create things that didn't exist just a few months ago. And so, that is encouraging to see how government can work. It can mobilize. We can work through the bureaucracy to make things happen. I think the collaboration between so many state agencies, the Emergency Management Agency, the School Board, you know, the Department of Corrections, I mean all of the agency coordination at that level, the coordination between IDPH and our local health departments. We've just been working in lockstep. So, our partnership with the hospitals. The hospitals have just been amazing partners in this pandemic. Really stepping up, doing what they had to do, even to their own financial peril, just to make sure that the people of the state got the care they needed. So, all of those have been wonderful, exciting, great surprises. But of course, I'm sure you've heard the same answer, just the politicization of safety measures. The mistrust of public health. Public health has always been in the background. Nobody knew who anybody was, who public health officials were. And now, for them to come out of behind-the-scenes to be in front of the scenes. And then, to be vilified that they have some horrible ulterior motive, is a little bit shocking. To have public health officials be worried about their safety is a little bit shocking. I'm concerned about those things. So, you know, there's been good, and then there's been not-so-good. And it's all part of this very challenging time that we find ourself in.
>> Howard Bauchner: A few weeks back, when you were talking about the deaths, you became quite emotional. And it was widely, it was widely reported. I think it's the human face of 10,000 deaths and, as you said, the missing chairs at Thanksgiving or the holidays coming up in December. When you think back now just a few weeks ago, when that happened and you turned away from the camera and Governor Pritzker was very reassuring, how do you think about that now?
>> Ngozi Ezike: No, yeah, that's a great question. At the time, I was beyond mortified. I couldn't wait for the press conference to end. And I ran back into the waiting room and was like, apologizing profusely to the governor for just losing it. And he again was so supportive, like, do not apologize for being a human. And those words have stuck with me. And the response since then was like I somehow let out some collective community cathartic release, I guess, that we wall needed to have. Because I'm still getting thousands of letters and messages and emails of such strong support that it seems like we all are in the same place. And sometimes, just always being the perfectly poised, composed person is too distant. And as I talk about us needing to connect hearts, maybe we have to let our emotions be on our sleeve every once in a while, so that we can have that heart-to-heart connection. Because this is what it's going to take to have everybody rowing in that same direction.
>> Howard Bauchner: There's one or two other questions came in. Then, we'll stop. I know you have other work to do. PPE. You've talked about, you've talked about the work with hospitals. And I think hospitals are in a very different place. I mean, even the numbers now, even though hospitalizations countrywide are about 60,000, they're much more spread out around the country, which is helpful. It's not concentrated in New England. Although I know you carefully watch the number of hospital beds that are being occupied by COVID, patients with COVID-19. But PPE was an immense struggle in February, March, and April. Is it your sense that the supply chain is better now, when you talk to the people who are hospital-based?
>> Ngozi Ezike: Yeah. So, everyone is so sensitive to the drama that unfolded and the scramble. I mean, we were literally reaching out to people saying, if you have any PPE anywhere, can you please send it to us. And so, I think the hospitals have been very diligent about, you know, amassing stockpiles to make sure that they are, they are ready for this now second wave that we find ourselves clearly in the midst of now. So, I think that PPE concerns should be less. But unfortunately, I think the numbers that we are going to see are going to be larger than what we saw in the first wave. So, in terms of what we thought would be a three-month supply, the projections might not actually be appropriate, and that that three-month supply might not actually last for as long. So, I think there still may be some challenges. Especially when we think about how much we've learned in terms of the clinical care. That it's not about putting people on a ventilator. Instead, you're thinking about proning people. And that proning effort takes more staff and more PPE, right. It's, you're talking about six persons. It's not just a single person coming in and adjusting dials on a vent. And so, the PPE needs are a lot greater because of the new techniques that we'll be using that have been proven to decrease the case fatality and the mortality rate.
>> Howard Bauchner: Yeah, these proning teams are really quite effective. And as I said, we really know steroids, for critically ill patients, steroids have become the standard of care. The good news is, it really reduces mortality. Some of the other drugs, it's a little unclear. Proning has really helped. And if you can prevent people from getting ventilated, the chance of survival, even if they're in the ICU, is really increased dramatically. Ngozi, you know, I see a lot of data, I read a lot of articles, I talk to a lot of people You have done a spectacular job.
>> Howard Bauchner: A spectacular job. You and the governor should go home and be very proud of yourselves.
>> Ngozi Ezike: Oh, thank you so much. It doesn't feel like it as we embark on this next wave. But the governor has been just an amazing leader. He's been an amazing leader. He has put the health of the people forward first. And I'm sure we're going to get through this. I know we're going to get through this. We have great leadership and dedicated individuals at all levels. And we, we're ready.
>> Howard Bauchner: Yeah, you and your team have saved thousands of lives. It's rare that I think a physician ever gets to say that. And I know it's not just you. I know it's you and your team. But you should feel like you've organized care in a way that thousands of people's lives have been spared because of your efforts. So, I just really want to acknowledge and thank you.
>> Ngozi Ezike: Thank you. Thank you so much.
>> Howard Bauchner: This is Howard Bauchner, Editor in Chief of JAMA. This has been Conversations With Dr. Bauchner. And I've been speaking to Ngozi Ezike, who actually is doing what we've been talking about for months and months and months. She's Director of the Illinois Department of Public Health. Ngozi, thank you. And please, make sure you and your family stay healthy.
>> Ngozi Ezike: Thank you so much.
>> Howard Bauchner: Bye- bye.
>> Ngozi Ezike: Bye-bye.
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