A Letter to President-Elect Biden

Attn: Mr. Joseph Biden, President-elect of the United States, and:

Members of President-elect Biden’s COVID-19 Advisory Board:

Dr. David Kessler, former FDA Commissioner

Dr. Vivek Murthy, former Surgeon General

Dr. Marcella Nunez-Smith, Associate Professor of Medicine and Epidemiology, Yale University

Dr. Luciana Borio, Senior Fellow for Global Health, Council on Foreign Relations

Dr. Richard Bright, former Director of BARDA, 2016-2020

Dr. Zeke Emanuel, Professor of Health Care Management, Medical Ethics and Health Policy and Vice Provost for Global Initiatives, University of Pennsylvania

Dr. Atul Gawande, Professor of Health Policy and Management, Harvard University

Dr. Eric Goosby, Former Global AIDS Coordinator

Dr. Celine Gounder, Clinical Assistant Professor of Medicine, NYU, journalist and filmmaker

Dr. Julie Morita, Executive Vice President, Robert Wood Johnson Foundation

Dr. Michael Osterholm, Professor of Public Health, Director of the Center for Infectious Disease Research and Policy, University of Minnesota

Loyce Pace, President and Executive Director, Global Health Council

Dr. Robert Rodriguez, Professor of Emergency Medicine, UCSF

November 18, 2020

Dear President-elect Biden and members of your COVID-19 Advisory Board:

I’m a physician who has spent the past eight months treating COVID-19 and developing COVID-19 clinical trial opportunities for my rural community in New York. I am a child of immigrants who grew up in a metropolitan area, but I’m raising my family in and plan to remain in the rural U.S. This is for many reasons my home, and as someone with a deep interest in both rural healthcare and the welfare of rural America, I am writing to express several concerns and to ask several questions of the advisory board.

My first concern is that, while the members of the board are collectively very accomplished and diverse, there are nonetheless still some diversity and experience gaps that exist. I’ll begin with diversity. There are no current residents of rural America that I’m aware of on the advisory board. Dr. Rodriguez is the closest exception to this, but he works in the San Francisco Bay area and even his hometown of Brownsville, TX lies within the metropolitan Brownville-Harlingen (population >400,00) area. As you know, nearly twenty percent of Americans live in rural areas. Rural America is a place of tremendous diversity, talent, resources and history. It is also, from a healthcare standpoint, the most under-resourced and under-recognized segment of our nation. How is it, for example, that over 200 rural counties (nearly ten percent of rural counties) still lack a single physician? How is it that so many rural hospitals are closing or have closed? How is it that there are still so few doctors in rural areas? How is it that the COVID-19 pandemic is now striking some rural counties so hard that nurses and doctors with COVID-19 are allowed to work so long as they remain asymptomatic? How is it that this isn’t talked about more? This last question is arguably the most important one in this list, because it reveals another problem with rural America’s healthcare system. This system not only operates in the shadows of the larger American healthcare system, but it does so with almost no national voice. We have seen what happens when a large group does not receive the attention it deserves. What results, among other things, is stagnation in the midst of progress. Now, with the COVID-19 pandemic striking hardest in rural counties, it is essential that this mistake not be repeated. Rural America must have a voice in this pandemic. To have no rural representation on this advisory board is, in my opinion, more than just a mistake. It is a misrepresentation of America itself.

My second concern is that it seems the board may potentially have limited experience in direct longitudinal care of hospitalized COVID-19 patients. Dr. Rodriguez offers experience in acute care of COVID-19, but as someone who has treated this virus for some time now I can tell you that it’s largely what happens after a patient with COVID-19 gets admitted to a hospital that truly determines their clinical course. I’m encouraged to see that there are several infectious disease physicians on the advisory board, but with this said it’s also my understanding (please correct me if I’m wrong as I’m relying on internet biographies) that none is currently working as a full-time clinician. With COVID-19, a patient’s clinical course can change dramatically from day to day and so there is tremendous benefit to watching a patient through the entire course of a hospital stay, no matter how long it may be. As these stays can last weeks or even months, I think it would be very challenging for anyone other than a full-time clinician to achieve true longitudinal care of hospitalized patients with COVID-19. In my own life, my clinical COVID duties alone often feel like a separate job, in particular when combined with the remainder of my clinical responsibilities. You may ask why this is important. You may even say to yourself that the board should be focused on the bigger picture. Its goal should be, to quote your own official statement, to help shape your approach in “managing the surge in reported infections; ensuring vaccines are safe, effective and distributed efficiently, equitably and free; and protecting at-risk populations.” This should perhaps be, in the opinion of some people, work for public health and policy-focused experts rather on the ground clinicians. I’m familiar with this kind of thinking, and yet here is why I believe that clinical experience matters. First, it is the only way to truly understand how the virus behaves. If you want to manage surges in infections, there is no better place to start than with a real world understanding of the various ways in which COVID-19 manifests in individuals and within communities. After seeing a lot of COVID-19 cases, a clinician begins to see trends that others don’t. They can often predict, based on a history and exam and a review of labs and chest images, who is likely to be infected. They can, based on an understanding of local infection trends and hotspots, often even predict when a local surge is likely to happen. These skills can help with everything from development of local testing and prevention programs to giving advice to local school districts regarding school closures to helping with timely procurement of PPE and key COVID-19 medications to providing assistance in developing local clinical research strategies for COVID-19.

Another reason why clinical experience is important with COVID-19 is that, if you want to protect at-risk populations, you need to begin with voices that those populations trust. Many people in my community have come to me to help them make sense of all the mixed messages they’ve received in the media. They trust me not only because they know me, but because they know the work I do. One of the advisory board’s challenges will be to develop strategies not only for ensuring adequate testing, treatment and vaccination of patients in rural areas, but also for convincing rural communities to do the right thing and wash their hands, maintain social distance and wear masks. To date, I’ve sensed that much of the mainstream media’s messaging on this issue has felt out of touch for many in my community here in New York. This messaging has felt national rather than local, urban rather than rural, monolithic rather than nuanced. To reach any person you must start with experience. Rural America is made up of many cultures and many places. To see it you will need the help of many people. Without clinicians and in particular without rural voices I believe this will be hard to do.

The following are questions I have for the board.

1) What are your plans for efficient, equitable and free distribution of SARS-CoV-2 vaccines to rural areas? Your plan to combat COVID-19 is both comprehensive and deeply needed (more on this below), but it still lacks--in my opinion--details regarding how you will overcome vaccine distribution challenges to our most rural places. With Pfizer’s mRNA vaccine, for example, cold chain disruption may be an issue with transport of the vaccine to remote areas. Furthermore, many financially struggling rural hospitals may be unable to afford the ultra-cold freezers required for storage of this vaccine. When vaccines that can be efficiently delivered to rural areas are developed at scale, how will you ensure that this will be done both efficiently and equitably? It will likely take more than the efforts of Pfizer and Moderna to supply SARS-CoV-2 vaccines to the entire U.S., let alone the world, and there is already a long track record in American medicine of rural places being left behind. With the likelihood that, at least in the beginning, vaccines will be a resource in short supply, what strategy do you have to make sure this consistent and old scenario doesn’t repeat itself once again?

2) As I’ve mentioned, nearly ten percent of rural counties don’t even have a single physician. Many small rural hospitals are struggling just to keep their doors open. Expensive COVID-19 medications such as remdesivir can be very difficult to afford for such hospitals. Furthermore, there is a well-known shortage of primary care physicians and a less well known but even more severe shortage of medical subspecialists in rural areas. How can a surge of any virus be properly managed and how can populations be protected in areas where there may not be sufficient testing supplies, personal protective equipment, hospital and ICU beds, ventilators, nursing staff, COVID-19 medications, regional transfer hospitals and/or even physicians to treat COVID-19 in the first place? What are your plans for addressing these gaps and for developing adequate healthcare infrastructure in rural areas both now and in the future?

3) The use of telehealth to deliver healthcare to rural areas has increased during the pandemic, and yet roughly a third of rural Americans lack high speed internet access. With many clinics moving to telehealth models in the pandemic, rural communities are already often lagging behind. You mention in your plan to combat COVID-19 a general plan to invest in broadband expansion. This commitment, coupled with existing funding sources for broadband deployment such as the USDA’s ReConnect program, gives me great hope. However, the deployment of broadband to rural areas is typically an expensive and longer term proposition. Assuming that telehealth will remain inaccessible for much of the rural U.S. during this pandemic, what is your specific plan and timeline for extending broadband to rural America during your first term?

There are many more concerns and questions that unfortunately I can’t fit into a single letter. There are also potential answers to the questions above which, in the spirit of not leading my own discussion, I’ve chosen not to include. For now, my goal is to begin a conversation.

I’ll close by saying that these questions and concerns do not undo my gratitude for the formation of this advisory board. I believe it is long overdue, just as we as a nation are long overdue for a change of course with this virus. I will also say that, as someone who has read the Biden plan to combat COVID-19 (https://joebiden.com/covid-plan/), I am confident that the board is already considering many if not all of the questions above. However, a search for the term “rural” within this excellent plan reveals only a single line, and that line concerns ensuring that training, materials and resources reach rural health clinics during the pandemic. To this, my question is, what about the rest of rural healthcare in the COVID-19 pandemic? What about its few and closing hospitals, its burned out medical providers, its failing and sometimes absent infrastructure, its developing world status within one of the most developed nations in the world?

There is much work to do and there are many questions to ask. My hopes in writing this letter are just to help bring the answers to these questions into broader daylight and, above all, to help ensure that no community is overlooked in our recovery from this difficult chapter in the history of our nation.

I appreciate the board’s time in considering this letter. I hope that, as you continue your work, you will all find a nation supportive of your mission to address the many unique and critical challenges posed by the COVID-19 pandemic. I, for one, am on your side. I look forward to your reply.

Eyal Kedar, MD

Potsdam, NY

References:

1) https://www.statnews.com/2020/11/11/rural-hospitals-cant-afford-freezers-to-store-pfizer-covid19-vaccine/

2) https://www.usatoday.com/story/money/2020/04/23/coronavirus-pandemic-218-us-rural-counties-without-a-single-doctor/111582818/

3) Pink G. Most Rural Hospitals Have Little Cash Going Into Covid. North Carolina Rural Health Research Program Findings Brief. May 2020.

4) https://www.ruralhealthweb.org/about-nrha/about-rural-health-care