Ellington

Twice now, LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine at the University of Mississippi Medical Center, has made headlines for her strong public stance on Mississippi's response to COVID-19. Gov. Tate Reeves' delayed statewide shelter-at-home order came on the heels of her impassioned letter to state leadership: "In my opinion, (a shelter-in-place order) is the only additional thing we can do right now to decrease the force of the impact," she wrote on April 1.

Then on May 4, Woodward cautioned on Twitter that the state had yet to see the peak of the virus, only days before Reeves expanded the state's reopening well in advance of the national guidelines. Her urgings reflect the challenges facing UMMC at large, responsible for both treating COVID-19 patients and, as the state's only research hospital, developing partnerships with state agencies to test, trace and eventually treat the disease.

Woodward spoke to the Jackson Free Press about the breakthroughs in testing and treatment at the medical center, as well as the state's larger coronavirus strategy.

Help me understand UMMC's role in the fight against COVID-19, both as a hospital and as a research institution.

That's my favorite thing to talk about right now. I'm glad you started with that. We are doing the things that every other hospital and health system is doing. Right out of the gate, as soon as the (Centers for Disease Control) recommendations, Department of Health recommendations and the governor's orders started coming out, we restricted our visitor policy.

We clamped down and stopped doing elective cases and canceled a lot of clinic appointments that can be postponed.

Then we started looking at our PPE (personal protective equipment) supplies. All of those things that everybody else did, we did that with a vengeance. There were a lot of things that we did that, because we're an academic medical center, we have the capability, the range of resources and expertise to be able to do.

As soon as we started wrapping our heads around what this virus meant and what things were happening all around the country, we started working fast and furious on an internal test development. That was really one of the game-changers, you know, developing this internal test.

We were doing a lot of work around things like making swab kits, because all of these supplies that we took for granted became very precious and very hard to get. We spent a lot of time and energy looking at alternate sources of PPE. So the test development was a very big thing.

We started early on looking at what was happening in the space of clinical trials, and now we're at a point where—I don't know our last number—it's between 12 and 15 clinical trials that we have stood up and available for patients in Mississippi.

We're the only site in Mississippi that's offering those.

When you say clinical trials, can you elaborate?

Yes, so for clinical trials for treatment, this is a virus for which there is no known identified treatment plan. And so we are now participating in a dozen or more national clinical trials that are treatment trials.

So different types of drugs are being trialed. Also, we've got a long existing, very good relationship with the Mississippi Department of Health and have partnered with them before at the state level in different disasters. So we very quickly, with their partnership, with (the Mississippi Emergency Management Agency) and with the Department of Public Safety, stood up testing opportunities at the Fairgrounds.

With the partnership we have with C-Spire, we developed—over a couple of days' time—an app for screening. We were able, right out of the gate, to participate with the Department of Health and to provide the medical expertise in screening at a statewide level and testing at a statewide level.

I don't know the number exactly, but by the end of this week, it's definitely north of 50, it may be close to 60 sites across the state where we have sent teams to perform tests in local communities, realizing that everybody can't come to the (Mississippi State) Fairgrounds for testing.

I wanted to ask about some of those pop-up testing sites. Will UMMC be shifting its focus to areas like Leake and Scott County, which are growing hotspots for the disease?

It's the Department of Health that determines the testing sites each week. I know that they are trying to factor in a number of things in those decisions. There are some communities in the state that either their local hospital or some other entity are performing some tests.

So not every community needs us to come in and do the testing.

The Department of Health—and I can't necessarily speak for their thought process—but they are balancing where there are needs and where there are requests, and trying to hit all the geographic regions of the state. I know that they are very much in tune to where they are seeing some increased activity.

I don't feel qualified to speak for them (MSDH), but I know we're having regular daily conversations with them, typically multiple times a day. I know that they are sending teams to some of those areas where they are seeing increased activity outside of the testing sites.

You talked about UMMC's in-house tests. Could you give me a quick update on how many tests the institution is performing daily? Can that procedure can be replicated elsewhere?

We've got three different vehicles for an in-house test. If you've been tracking it, we might have an announcement one week that, now we can do 200 tests, and the next week is 400, and the next week is 600 or what have you.

And you think, why does the number change? It hasn't been going down, but we've been able to add additional capacity. That's because we've got three different ways that we're doing the in-house tests. The first test that we did was a combination of an in-house process integrated with a commercial product. So it was sort of a half in-house and half-commercial integrated lab test.

That's the one that we were able to get out of the gate first. Then we have what we're calling a lab-derived test, which is from start to finish completely in-house developed. So that is pathway number two.

Then we have pathway number three, which is using the commercial Cepheid product, which you might've heard of.

It's one of these commercially available products that they count as a 45-minute test. What that means is it takes 45 minutes, when you get the sample on the machine, until it's done. But with the entire time of getting the sample, it's really about a four hour turnaround. So right now, we're able to work those three modalities.

And our capacity right now is around 625 to 630 per day. Now it depends, in some cases. For example, that Cepheid test, our third pathway. We have (chemical) reagents right now to run about 200 of those tests. We're going to run out of those in the next week, and we don't know when we're going to get more reagents.

So part of our capacity for running these tests depends, particularly for those two that require commercial products, on how much of that we can get and when we can get it. As you might imagine, we are in the fight with everybody else in the country in trying to get these materials.

So I feel confident in saying our test capacity right now and for the foreseeable future is north of 600 per day. If we can get access to more of the Cepheid product, we can increase that. And we are working to increase the capacity of our lab to run tests so that we can get north of a thousand. But right now that's still another couple of weeks out probably.

We're looking at all the different avenues to increase our testing capacity.

We are testing for our own patients, for several other hospitals in the state, and we are doing some tests for the Department of Health. We're running some of their specimens that are collected, so we are trying to increase our capacity.

You've been supportive of an abundance of caution since the early days of COVID-19 in Mississippi. Your letter to Governor Reeves preceded the statewide shelter-at-home order. More recently, you tweeted that Mississippi has yet to enter its peak, something that the numbers are continuing to bear out. Is Mississippi opening too quickly?

We have not hit our peak. I'm trying to read everything that I can read, and talk to our own in-house specialists.

I have become personally convinced that, unlike maybe the expectations back in early March that all this was three months and then we'd get on the other side of this. ... I have become convinced that we are going to be faced with this challenge for a year or 18 months. I don't think that this is going to go away anytime soon. And I say that because we don't have the ability as a state, or a nation, or a medical center, or a people, to know the prevalence in the community. We don't know really how prevalent this is.

There are things that may look encouraging, but as it stands today, we don't have a proven, effective treatment. We don't have a proven vaccine. I think that's a number of years out, or at least a year or so out at best. This is a tricky virus. It is causing a lot of bizarre symptoms that people are having a hard time explaining and piecing together the exact mechanism of the virus.

We're starting to see some mutation of the virus. I can envision a future where, similar to the flu, every year we're chasing the mutation of the year. So my point is I don't think we can shelter as a state or as a country. I do not believe we can shelter-in-place through the completion of the cycle of this virus. I don't think that we can. When you look at the economic impact, it is unhealthy for an individual, and it is unhealthy for a community for people to be unemployed and lose their job.

Not to be able to pay their mortgage or their rent, not be able to buy their medication, not be able to feed their family. That is unhealthy as well.

So I personally feel a great deal of—I don't know if sympathy is the word or empathy is the word—for the governor and for the leaders that are having to balance these two very, very difficult things.

What we have to do as we are opening back up the world, the community, the country is, be smart about it. Because it is a very contagious virus.

It has the effects of which are often unexpected, the range of impact it's having on an individual patient who gets sick from it is very broad. It is not just a respiratory virus. We are seeing renal failure. We are seeing blood clots. We are seeing (central nervous system) effects.

It is a wide-reaching virus in its effect on individuals that get sick with it, but the truth is while I would love from a medical standpoint for us to do everything we can do to reduce the spread, we can't shelter-in-place for the duration of this virus. I've become convinced of that.

What does a responsible opening look like?

In my opinion, the responsible opening is where we continue to do as much distancing as we can. People (should) continue the hand hygiene—of all the things that we do, that is the most important thing.

Don't touch your face. I think continuing to wear masks, while it is not the perfect solution and it does have its own negative consequences, I do think that for most people, it is a positive thing. I don't think we'd go back to shaking hands with everybody, yet. Boy, in Mississippi, that is a hard tradition to break.

I think we have to continue to be very cautious not to be around people who are sick. If you yourself are sick, you need to self isolate at home. We need to continue to take care and wipe down surfaces with disinfectant. ... I don't think that we need to start congregating back in bars and being 12 inches away from people.

All of those sorts of really close encounters. I think that's really where there's been the greatest risk that large numbers of people will get sick.

Fifty-percent capacity for dine-in services at restaurants begins May 7. What's your medical advice for Mississippians? Is eating at restaurants safe?

I think the safest thing would be to not (dine in at restaurants.) But I think the emotional place we all are is we're ready to do it. All I can say is, let's be smart about it.

I've seen some things out of other countries showing, for example, the seating chart of the restaurant where an infected individual was sitting in front of the AC unit. It's a ray of infections all the way across the restaurant. Are you worried that, in an enclosed space, that distancing will not be enough?

Absolutely I'm worried. Part of my worry is just like you mentioned, an individual who may be shedding virus in front of an air vent.

But the other reason that I'm worried about gatherings of people in enclosed spaces and other things like that is we do know that somebody, I, you, anybody could be infected with the virus and shedding for a few days before they become symptomatic.

That's part of what is so frustrating about this is. As we start getting out and getting around—and like I said, I think there's just no way to shelter in place for the duration of this virus—we've got to realize that there's some inherent risks, because people can shed virus and be contagious before they know they are sick.

How do we know if and when we are loosening up too quickly? Is there a rate of infections or a number of infections that would suggest that we need to pump the brakes?

I don't have a number to give you, but I know that Dr. (Thomas) Dobbs and myself, state leadership and all the medical professionals, and I'm sure the community at large will be watching the number of patients that have to be hospitalized. And we'll be watching the number of deaths.

If we see big outbreaks around the state, I think that at the very least, we'll have to take local measures to have some containment in those areas.

Now, the number of positives will go up. Because we're trying at the state level to test more people. Because we're trying to learn how many people have this.

Right now we don't have confidence in the numerator, and we don't have confidence in the denominator, because there's not complete, widespread testing. So the number of positives will go up.

But what we really need to be tracking is how many patients require hospitalization, how many patients are very sick, and how many patients are dying.

We've got to take what we've learned as a state, as a medical center, and as a country over the last few months, to help us respond more quickly and more effectively where we see spikes in numbers. Even though there are many questions that we don't know the answers to, we have learned some things.

There are some troubling trends nationally and here in Mississippi as well. One is obviously the racial disparities of COVID-19. Black women are massively overrepresented in the contraction of coronavirus, and black men are highly overrepresented in deaths. How do we address that short term and long term?

There are definitely research studies that need to be done in this space. We are watching for funding opportunities and grant opportunities.

I hope that some of those become available. I think they will be. I think that Mississippi would be a wonderful place to be able to conduct some of those studies.

That's looking at the longer term. (We should) really find out if there is something about this virus and the way that the virus works that accounts for those.

In the short term, I think what we have to do is be extra vigilant and alert to patients who have existing comorbidities, whether it's rates of diabetes, hypertension or heart disease.

We know that all patients that fall in those categories are at higher risk. We've got to be certain that we are getting the right message out to everybody about the right steps to take from the standpoint of distancing: hand hygiene, all of those things.

So short term, I think we do what we're doing and do more of it.

Long term, we've really got to figure out what is the reason for these differences. We don't know what it is right now.

I had a conversation with Lt. Gov. Delbert Hosemann last week, and we discussed preventative health measures. What is UMMC thinking for no or low-cost preventative health solutions that could address some of these health disparities?

We've got a Department of Preventive Medicine, and we have a School of Population Health. And both of those are relatively new. The intent of both of those is to really help us understand some of these underlying health issues that affect populations in Mississippi. So we've got that area of focus.

Like I said, it is relatively new. We are looking at the ways that we can use technology and other things to expand our ability to do chronic-disease management and to reach patients through telehealth, remote patient monitoring and other things (if they can't) get to Jackson.

It's a challenge for them. We've looked at some pilots using remote patient monitoring with a group of diabetic patients that were in the Delta, things we can look at as a small scale. I don't have an answer to give you today, but access is a major obstacle to care, distance is an obstacle to care, and (so is) access to technology.

So we're trying to look at all of these ways that help us address the challenges that patients have in their own home, in their own environment, without them having to come to the medical center to see a diabetes specialist every other month, or something like that. It is a multi-pronged challenge and a problem that will take multiple layers of work to address.

Everyone hates it when I ask them this question: Is there a single better preventative health initiative than Medicaid expansion?

I don't know what the right answer is. I spent about 20 years here working in our adult emergency department. From that perspective, you see all the failure points in our system, you see all the patients that didn't have regular access to care. You see the diabetic patients that present, basically, a diabetic coma, whereas normal access to care would have given them a whole different kind of a life.

So you see all the failure points. And like I said, there's not one solution. I do believe that anything we can do as a state to improve access to care is a benefit to the patient. And whether that's Medicaid expansion, whether that is some other program, I don't feel like I'm qualified to say what that looks like, but what we need is improved access to care.

Part of the problem, and I know I'm side-barring a little bit, but part of the problem is you look around the state of Mississippi at the workforce—the health-care workforce. There are a lot of communities where one of the major problems is access to care in a clinic.

It's having health-care personnel there. It's the physicians per capita in the state of Mississippi. We're last. That was part of the driving force, now 15 years ago, when we first started increasing our class size in the medical school. It's because we were last in physicians per capita. That's not the solution to the problem we have in Mississippi, but when you're last it's part of the issue. So it's not one single thing that we as a state can do to get that access, but there are a lot of pieces to that puzzle.

Intern Julian Mills contributed to this report. Email [email protected].