Editor’s Note: In this BC Law Magazine “Vision Project” series, we are engaged in a lengthy discussion with Boston College Law School faculty about where the Covid-19 pandemic and its attendant medical, economic, racial, and political consequences may lead us. As New York Times op-ed columnist Timothy Egan so eloquently put it recently, “Every crisis opens a course to the unknown. In an eye-blink, the impossible becomes possible. History in a sprint can mean a dark, lasting turn for the worse, or a new day of enlightened public policy.” There are warnings and worries in these professors’ views, but there are also farsighted ideas and strategies for crafting a better future, a more just society, and a world in which each and every human being is equal under the law.
ASSOCIATE PROFESSOR DEAN M. HASHIMOTO
Not only is Hashimoto a law professor, he is also a public health scientist and practicing physician. At Massachusetts General Brigham he oversees the health and safety of workers in the twelve-hospital system.
Let’s start with the work you’ve been doing to increase workplace and patient safety in hospitals during the pandemic. I provide leadership as the chief medical officer in Workplace Health and Wellness, a division of Mass General Brigham. This division consists of clinical services for health care workers at the hospital clinic sites, provides injury and illness prevention programs, and supports research in association with the Harvard Center for Work, Health, and Wellbeing.
Looking back, we were reasonably well-prepared for the pandemic. Last year, we instituted a mandatory annual flu vaccination program for all employees, including those not working at the hospitals. Our flu policy is based on the idea that all employees in a health care system should be a model for our patients and participate in this public health program that reduces the danger of infectious epidemics. Since the Covid-19 epidemic occurred during flu season, this mandatory vaccination program substantially reduced the number of employees who became ill with symptoms identical to the coronavirus illness.
We anticipated the high demand on occupational health services by 77,000 hospital workers through leveraging technology early in the epidemic. In February, we implemented several new electronic reporting systems. When the CDC began to issue warnings about overseas travel, we were the first in our region to establish a travel survey that was completed by all employees traveling to China and other high-risk countries. When the CDC later issued furlough requirements for those who returned from travel to these Level 3 countries, we were literally pulling people out of work during the same day that these requirements were issued. The travel data were an invaluable means of protecting our patients and workers.
Our basic strategy was highly focused on implementing key CDC guidelines. The danger of trying to reduce all potential risks to zero is that you will not prioritize the safety interventions that will have the most substantial impact. We took the more practical approach of emphasizing five key CDC recommendations and implementing them exceedingly well.
So, we emphasized respiratory hygiene, washing your hands, physical distancing, and a masking policy that required both patients and employees to wear surgical masks. Shortly after initiating universal masking, we saw a substantial decrease in the number of infections among our health care workers. We were perhaps the first health system in the country to initiate universal masking, and we published this important data in the <i>Journal of the American Medical Association<i>.
We also instituted a symptom report that later transformed into what is called the FastPass system whereby, in order to enter the hospital, you have to record daily on a phone app whether you have any symptoms of disease. Then, once you receive your staff pass on your mobile device, you show it to the person at the door who will let you into the hospital and provide a surgical mask to wear for that day.
Our most innovative achievement was putting together the occupational health call center. The call center receives phone calls from employees about any Covid-related issue, but especially if they have symptoms and want to be considered for testing. When testing first became available, we were able to offer it to everyone in a reliable way. We needed, however, to increase the size of our occupational health staff more than three-fold within two weeks. That’s what the creation of the call center allowed us to do. We basically went from 35 clinicians to over 100 clinicians, most of whom are devoted to the Covid-19 epidemic. The call center makes testing readily available and provides advice to concerned workers. It helps track the health of workers and ensures that they are cleared medically before returning to work.
What parts of the hospital did you find were most susceptible to Covid-19 infection? It was reasonable to worry that those who were working in the ICU with Covid-19 patients would have a high infection rate. But we found that, at least in our hospitals, that was not where infection rates were highest. Infection rates were highest among those departments with low paying jobs. If you look at our various job categories with lower wages—food service workers, environmental service workers, and so on—their infection rates are up. What we’re seeing is basically a reflection of the risk of transmission in the community.
The renowned medical writer and thinker, Dr. Atul Gawande, described our CDC-focused approach to hospital safety at Mass General Brigham in <i>The New Yorker<i> on May 13. He noted that we have had “few workplace transmissions” and observed that our hospitals have “learned how to avoid becoming sites of spread.” Dr. Gawande concluded that this hospital safety approach provides a regimen for our society’s reentry to the new normal in the face of the pandemic.
If you were to start from scratch, how would you build a health care system that is humane and effective and just for all? What this epidemic reveals is the importance of workplace health and public health in health care. In fact, the curve did flatten in Massachusetts and other states. The number of people infected with coronavirus and who have died is tragic. But the tragedy is a lot less than what it could have been. I hope this means that there will be an even greater recognition of the value of public health, and a greater commitment to it.
Public health has a broader focus than medicine. It looks at the social determinants of health. The Covid-19 epidemic has revealed that the basic injustice within health care, and in public health more generally, is tied to socio-economics. It’s tied to disparity in wages, housing conditions, transportation access, food distribution, and other social determinants of health.
As a country, we spend more than two-and-a-half times what is spent in the average industrialized country in the world. Yet, in terms of health outcomes, we’re below average. We haven’t paid enough attention to the social determinants of health.
What are the impediments to, and opportunities for, achieving a more equitable system? I support the vision of a Medicare-for-All system or a single-payer system. But that’s really a ten- to fifteen-year vision. It’s not going to occur very quickly even if we make that commitment now because of the number of large steps necessary to get there, including the expansion of Medicaid/Medicare and the abolishment of private health insurance. If I were to pick one thing that I would like for the next presidential candidate to be committed to, it would be climate change. The pandemic creates the unusual opportunity to maintain our reduction of global pollution. Climate change is the most important public health issue of our generation and is having a disproportionate impact on vulnerable populations because of the social determinants of health.
Read all faculty Vision Project interviews here.