Dean's COVID-19 Commentary

The COVID-19 pandemic has rescaled time into Before COVID-19 (BC) and After COVID-19 (AC). In this calendar, we are now well into AC year three. I can still recall specific days in the early AC period and the decisions that were made in March 2020: moving to remote education and closing the CU Anschutz Medical Campus. The Colorado COVID-19 Modeling Group was launched synchronously with these events; the team quickly began forecasting the trajectory of the pandemic with implications for government action at the state level.
 
If you want to go back in time to that period, read The Desperate Hours: One Hospital’s Fight To Save A City On The Pandemic’s Front Lines, by reporter Marie Brenner. The book is about the New York-Presbyterian hospital system under stress from the pandemic. Brenner was given open access to this enormous system and its health care providers and administrators. The resulting book is quite long at 460 pages, befitting the many stories that Brenner tells as she shifts from providers to patients to administrators. Sometimes the storytelling is too complete, offering accounts of the parents and grandparents of many of the key players, for example. The reporting is so dense that there are names that I recognize and people whom I know.
 
There are many reminders in this lengthy book of the start of the AC epoch: the initial problems with obtaining testing, the lack of personal protective equipment (PPE), the nightly celebration of health care providers in New York City by its residents, and the uncertainty as to how to manage patients with this new disease. Some of the familiar themes: modelers trying to establish credibility as they projected the number of patients the system may need to absorb and health care professionals searching desperately for PPE; coping with impossible patient numbers while trying to maintain a humane approach; and displaying incredible resilience. There are heroes—ICU directors, critical care providers, anesthesiologists, nursing supervisors, and some of the lead administrators. Of course, the pandemic is the critical villain, but there are human villains—such as remarkably tone-deaf administrators who were too distant from the frontlines. Brenner points out that concerns about the financial consequences of the pandemic were sometimes too dominant.
 
While the book is about the New York-Presbyterian system, the experiences recounted by Brenner have universality. We know that there were heroes everywhere in the early days of the pandemic and their heroism saved lives, sometimes at high personal cost. And counterparts to the somewhat stereotyped villains in Desperate Hours were likely ubiquitous. I can relate to the doubts of the modelers as they contemplated the consequences of their findings and mistaken assumptions. This is a book by a reporter lacking the analytical acuity that could have more sharply captured lessons learned. I worry that we are forgetting those lessons in AC year three. The emerging monkeypox epidemic, now declared a public health emergency of international concern by the World Health Organization, is a current test case. Read Scott Gottlieb’s weekend commentary: Monkeypox Is About to Become the Next Public Health Failure.
 
Polyfluoroalkyl and perfluoroalkyl substances (PFAS) were also in the news last week. A Denver Post story described widespread contamination of water in Colorado by PFAS at concentrations above the Environmental Protection Agency (EPA)’s recently announced drinking water health advisories for four PFAS compounds. This broad group of chemicals has been widely used in many applications because of their surface properties, for example, nonstick cookware and fire-fighting foams. The compounds are long-lasting, and, after more than a half-century of use, they are in water systems throughout the United States. They can be detected in biospecimens from a substantial proportion of the population. While the scientific evidence is still evolving, PFAS have been linked to diverse adverse effects on health, including possibly being carcinogenic.
 
The EPA released the health advisories as it anticipates new regulation for two compounds, PFOA and PFOS, in the fall of 2022 under the Safe Drinking Water Act. The new health advisories substantially lowered the target concentrations based on information since 2016 when the current levels were announced. The process of setting the new regulatory maximum contaminant level goals (MCLG) for PFOA and PFOS is complex, lengthy, and evidence-based. Several weeks ago, the Agency’s Science Advisory Board (I am a member) reviewed four documents prepared for that purpose, including systematic reviews and weight-of-evidence determinations on causation of adverse health effects and the associated risks. In its in-depth review, the board found substantial flaws in the underlying methodology, leading me to comment that: “The comments make clear that EPA’s approaches to gathering, synthesizing, integrating, and applying evidence are lacking and not the ‘state-of-practice.’” Revisions are underway. We need a high-quality bar for using science in decision-making; the Science Advisory Board serves to address whether that bar is met.
 
Colorado School of Public Health faculty members are advancing our understanding of the risks of PFAS. As part of a Centers for Disease Control and Prevention multi-site project, John Adgate in the Department of Environmental and Occupational Health is leading research on PFAS exposure in El Paso County. Ned Calonge, the incoming Associate Dean for Public Health Practice, chaired a committee of the National Academies that released a PFAS-related report last week: Guidance on PFAS Exposure, Testing, and Clinical Follow-Up. The committee was tasked with providing guidance to clinicians on measuring blood PFAS levels and on the interpretation and implications of the results. This is a challenging task in the face of substantial uncertainty but it was thoughtfully addressed by the committee.
 
The legacy of PFAS will be lengthy, given the longevity of many of these compounds and their potential adverse effects. There has already been landmark litigation, a book, and a movie.  Colorado School of Public Health faculty will continue to engage with this issue as we sort out the consequences of PFAS through further research.
 
And, the pandemic in Colorado? Hospitalizations remain stalled last week at 313, but test positivity and case numbers are falling. Given the lag between the latter two leading indicators and hospitalization count, perhaps the epidemic curve is bending.
 
Enjoy summer’s last weeks.

Jonathan Samet, MD, MS
Dean, Colorado School of Public Health