PIVOTED TO FACE COVID-19.
On a Saturday night in early February, Michael Good and his wife, Danette, were watching figure skating when something caught his attention. As the Chinese superstar pair Han Cong and Sui Wenjing spun to their sixth win at the Four Continents Championship in Seoul, Good noticed the audience behind the skaters. The lights were down, and the camera panned quickly, but he could see that there was something different about the people in the stands.
Virtually all of their faces were covered by masks.
“It certainly stood out to me,” Good recalled. As the CEO of University of Utah Health, senior vice president of Health Sciences, and dean of the School of Medicine, Good was following news reports on the growing outbreak of COVID-19, the disease caused by the coronavirus. The doctor from Wuhan who first sounded the alarm about the virus—Li Wenliang—had died just two days before. The director-general of the World Health Organization (WHO) had just declared the virus a public-health emergency of international concern.
With this knowledge, the masks in the audience made Good pause.
“It showed an active and large-scale health response in a public setting,” Good said. Knowing that there had been several viral outbreaks in Asia in recent decades, most notably with severe acute respiratory syndrome, or SARS, in 2002, Good understood that the population and governments there had some experience with such preventive measures. “But it’s not something we’ve experienced here in our country, to see an audience at a public event wearing masks—certainly not in my lifetime.”
That would soon change. Within weeks, Good would find himself standing with fellow health leaders alongside Utah Gov. Gary Herbert, urging the citizens of Utah to wear masks.
At the time of this article’s publishing, it is December—a year since the disease known as COVID-19 was first observed. Much has happened since then. Globally, more than 65 million people have been infected and more than 1.5 million have died. A number of vaccines have been reportedly developed, and society is undertaking public-health measures at an unprecedented scale. The disease has even reached into the halls of power—including the president of the United States. There have also been ripple effects: The global economy has been thrown into a recession, racial and societal inequities have been dramatically exposed, and the nation’s frayed political landscape changed in the recent election.
Here in Utah, cases are the highest they have been at any time since the start of the pandemic, having passed 4,000 cases per day. Nearly 600 are currently hospitalized—a number that is straining the capacity of not only University of Utah Health, but of the entire region’s health system. In response, front-line workers at the U and elsewhere are pushing themselves to the limit, grappling with fatigue and a range of emotional stresses. Governor Herbert recently declared a statewide set of new restrictions, including the wearing of masks.
Many more measures will likely have taken place between this point and the publication of this mag- azine’s issue. As the reader, you will undoubtedly be privy to even more information.
But if the outbreak of a pandemic is the health equivalent of war, then how do leaders respond when they are in the fog of it?
This article examines the first months of University of Utah Health’s response, as seen through the eyes of a number of key leaders. To assemble this report, we spoke to more than a dozen health care providers at various levels and examined news reports and public records published since January.
By necessity, the picture is incomplete. It is incapable of thoroughly cataloging the response of thousands of employees and citizens. And without a viable vaccine, the pandemic is entering a new phase this winter as people spend more time indoors where the virus can spread more easily.
Yet a successful response today and in the future depends on the choices made during these first six months, when University of Utah Health pivoted its entire system quickly to create dedicated care units, initiate sweeping new research initiatives, and inform state and public policy.
This is a story about the beginning of a crisis for which the end is not yet known.
THE FIRST WARNING SIGNS
In late January, U of U Hospital epidemiologist Jeanmarie Mayer was on vacation in Scotland when she received a call from colleague Nathan Hatton, associate director of the medical intensive-care unit (MICU).
“The reports coming from China are beginning to get real,” Hatton said. On the seventh of that month, CNN first reported that a mysterious pneumonia affecting nearly 60 people had broken out at a seafood market in Wuhan. Less than 10 days later, the virus was reported in Japan. The first case in the US appeared in the state of Washington on Jan 21.
“I hadn’t even brought my laptop with me to Scotland,” Mayer said. “So, I had to scramble to get information.”
As an infectious-disease specialist, Mayer was in charge of what to do in the event of an outbreak at the hospital. In 2014, she and Hatton created a special team within the hospital known as Code Bio in response to the emergence of Ebola that year. While that virus eventually faded, they developed a series of protocols over the following years for how university staff should respond in the event of a new outbreak, including how to triage patients, assess their contacts, and activate the infection prevention-and-control teams.
Mayer and Hatton realized that the protocols were now rapidly becoming necessary. “What we were seeing coming out of Wuhan raised all of the warn- ing signs,” Mayer said. “The disease was new, highly transmissible, and was causing some strong reactions in patients. In only a couple of weeks, it leaped across the ocean. This could be the kind of event we had been preparing for.” As soon as Mayer returned, university leadership issued a refreshed memo on protocols with directives for communication.
Shortly after, on February 11, the World Health Organization officially recognized the outbreak in the International Classification of Diseases and named the virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it caused—COVID-19.
THE CRESTING WAVE
In early March, Good convened a new task force in the boardroom on the fifth floor of the Clinical Neurosciences building.
Cases of COVID-19 were now growing in New York City and the state of Washington. It was only a matter of time before it would reach Utah. Good recognized that as the only comprehensive academic medical center in the Mountain West, U of U Health would play a leadership role for the state.
Several priorities emerged: develop and scale up the hospital’s action plan to care for patients; provide for the safety of staff, faculty, and students on campus; coordinate with state leadership and other centers; and join the international research effort to understand the disease. There were also financial implications. What resources would be required? What would be the impact of postponing elective surgical procedures?
Robert Pendleton had already been tapped to head up the hospital’s overall effort and network of clinics. For the past eight years, Pendleton had served as the top medical quality officer, overseeing a period when U of U Health rose to earn national accolades for the value and quality of its patient care.
Pendleton pulled Tom Miller, the hospital’s chief medical officer, aside and said, “Just so you know, I don’t have experience with a pandemic of this nature.” Miller replied, “I think it’s fair to say none of us really have. But you do know us.”
Pendleton started with the protocols built by Mayer and Hatton, then brought together different groups: “We asked things like, ‘How do we more than double our bed capacity in the next month? Where do we find beds and equipment? How would we find nursing staff, providers, residents, and pro- tect cleaning crews?’” Plans rapidly evolved as the teams hastened to implement them.
One advantage that Pendleton was thankful for was the U’s partnership with ARUP Laboratories. Rapid testing and contact tracing were essential to understanding and possibly containing the virus. But since it was so new, tests were only just beginning to be developed, and the turnaround time for high-qual- ity tests could take days—even weeks in some parts of the nation.
On March 12, U of U Health opened its first negative-pressure tents—which allow the air outside to get in but filter any air leaving the space—outside of the hospital to screen for coronavirus, making it one of the first hospitals in the nation to do so.
STATE OF EMERGENCY
Brian Shiozawa is deeply familiar with the intersection of health care and policy. In addition to working for two decades as an emergency physician at St. Mark’s Hospital in Salt Lake City, he served as a state senator for four years and then regional director for the US Department of Health and Human Services before joining the U as associate vice president of health policy in the spring of 2019.
So it came as no surprise when Governor Herbert asked Shiozawa to serve on a new task force to advise the state’s COVID-19 response.
“I remember sitting in the capitol at our first meeting,” Shiozawa said. “With cases popping up around us, we made a recommendation that day that the governor should declare a public emergency to give him some nimbleness to dispense available state funds and apply for federal aid.”
Herbert did so the next day and within hours, news broke of the first case within the state—a man in Davis County.
COVID-19 had come to Utah.
“You could tell right away that this was going to be a once-in-a-century kind of event. It was not only a health crisis but stood to be an economic and societal one,” Shiozawa said. “The state would need every resource available to respond, and the University of Utah would play a pivotal part.”
“Today, we stop making decisions based on a hope that things will get better and start making them based on the assumption that things will get worse,” Herbert declared at a press conference on March 12. Standing next to him were Good, University of Utah President Ruth Watkins, state epidemiologist Angela Dunn, and other leaders from across the state.
Watkins announced that the university was moving to online classes and that most staff across campus had transitioned to working from home. “These actions are designed to promote health and well-being on our campus and to support the well-being of our larger community,” Watkins said.
Standing before a wall of monitors displaying public health data, Good warned that a cresting wave of cases could overwhelm the system and asked for help to “flatten the curve” down—a phrase that would become commonplace in international discourse.
“‘Bend the curve,’ ‘physical distance,’ ‘PPE’ ... these were all new terms to most people,” Good said. “I felt that part of my role as a health leader and educator was to inform the public about these concepts. If we’re going to succeed to any degree, it depends on the partnership of the people of Utah.”
CASES BEGIN TO SPREAD
The same day that Good appeared on television, Clement Chow, assistant professor of human genetics at the U, suffered from shortness of breath. At the urging of a friend, he decided to check his blood-oxygen level using a pulse oximeter, a device that he happened to have. Regular readings lie between 95 to 100 percent, and any reading at 85 or below means a trip to the hospital. His device measured 70 percent.”
Chow became the first official case of COVID-19 at University of Utah Health.
His lungs showed the classic signs of bilateral inflammation, and he was quickly moved to Hatton’s MICU and put on high-flow oxygen. “I could feel the oxygen flowing to my extremities,” said Chow, who chronicled his experience on Twitter. “I thought, ‘This is what breathing feels like.’”
Chow was able to return home after several days, but it took him weeks to fully recover. A small but steady stream of new cases in the state followed him. Utah Jazz center Rudy Gobert became the first NBA player to test positive for the coronavirus, leading to a leaguewide shutdown. School districts, restaurants, and ski resorts closed. Grocery stores reported a run on cleaning supplies. The city’s marathon was canceled.
There was also a growing shortage of personal protective equipment, including N-95 masks, gloves, and face shields, as well as ventilators—items generally taken for granted by health-care professionals.
People across the state responded with expressions of support, volunteering their resources and time to help. The hashtag #UtahCares went out across social media, and through a statewide program, Project Protect, a collaborative effort of U Health, Intermountain Health Care, and LDS Charities, thousands of people sewed and donated more than 5 million masks.
A CALM BEFORE THE STORM
U of U Health leaders kept an eye on what was happening in the rest of the country. Over just one week in March, the daily number of new cases in New York state increased nearly more than 25-fold, accompanied by a dramatic increase in hospitalizations. Reports described emergency rooms overwhelmed with patients, a severe shortage of ventilators, and deserted streets echoing with the sound of ambulances.
“Watching what was happening in New York at the time was terrifying,” Pendleton said. “But it also served as a warning. It gave us advance notice of what to prepare for.”
The U’s hospital could care for 30 COVID-19 patients at that time. In the MICU, Hatton had already expanded the number of negative-pressure rooms from four to nine, but if there were a surge like what was happening in New York, he would need to double the capacity yet again.
Officials identified a recently vacated surgical wing that was slated for remodeling. The renovation was put on hold so that the area could be repurposed into a dedicated COVID-19 unit, a change that would require significant infrastructure investments. New air-conditioning units with particulate filters were retrofitted into the wing, and special entrances were set up to minimize contamination. The modifications would take two months. Until then, they would need to continue to use existing facilities.
Everyone braced themselves for a deluge.
But the surge had yet to come.
“Based on Italy and New York, we were expecting an immediate flood of cases,” Pendleton said. “Instead, we saw a steady trickle.” In March and April, the U saw an average of four to five patients per week.
“The only conclusion we could draw was that the public-health measures were working,” Shiozawa said. “People were staying at home and social distancing.”
The good news, however, did not extend to everyone.
AN IMBALANCED AND UNEQUAL SYSTEM
Across town, José Rodríguez knew that he would be seeing more patients than his colleagues. As associate medical director for the Redwood Health Center in South Salt Lake, the patients that Rodríguez saw were diverse and came from historically underserved families. Traditional viral outbreaks like the seasonal flu often hit this population hard.
In late April, Rodríguez was named the associate vice president for U of U Health’s Health Equity, Diversity, and Inclusion, a post he had been holding as interim since 2018.
“I’ve spent my career studying inequities in health care,” Rodríguez said. “I knew professionally and from my own experience as a Latinx that a pandemic would disproportionately affect minority communities.”
Several factors combined to amplify the impact of COVID-19 in certain areas. In Utah, as in many other states, the jobs held by many minority workers could not be transitioned to remote work. “You can’t dial in through Zoom to a farm, factory, or meat-packing plant,” Rodríguez said.
Then there was the difficult task of education. There are more than 120 languages spoken in Utah. “And there’s also a cultural barrier to the idea of social distancing,” Rodríguez said. “I’m of Puerto Rican descent. The idea in my own family that we can’t hug—it’s like asking us to surrender a part of who we are.”
Access to health care is also wildly uneven. Many families were uninsured or faced long commutes to the nearest facilities. And even with access to free clinics, a stigma against and fear about going to the doctor per- sists in many of these communities
“Imagine having a job that if you miss three days, you could be fired,” Rodríguez said. “A trip to the doctor can seem perilous. The truth is that we have a system that actively discourages certain populations from getting care.”
These elements set the stage for the coronavirus to spread like a fire through a dense forest absent of water. According to the Utah Department of Health, Hispanic and nonwhite workers—representing 24 percent of the workforce—accounted for 73 percent of workplace outbreaks from March through June.
Of particular concern was the rise of cases in San Juan County and the Navajo Nation, where daily counts began to spike. While the total counts were lower than in urban areas, the infection rate on May 1 jumped to 200 per 100,000 people, more than 20 times the rate in Salt Lake City.
U of U Health pivoted resources, sending staff and support to the Redwood Clinic. A mobile health unit funded by the Larry H. and Gail Miller Family Foun- dation for the Driving Out Diabetes Initiative was repurposed for COVID-19 screening throughout the Salt Lake Valley. By mid-October, it had conducted more than 8,000 screenings.
A RESEARCH FAMILY
If COVID-19 became the main topic of conversation within families, then perhaps few discussed it at the dinner table more than Emily Sydnor Spivak and Adam Spivak—when they actually could grab dinner. Emily and Adam met during their residencies at Johns Hopkins University and married, eventually moving to Salt Lake in 2012. Emily specializes in infectious diseases, and especially in the use of anti-biotics. In the fall of last year, she became a scientific advisor on infectious disease to the Centers for Disease Control and Prevention. Adam focused on HIV treatments and recently established Utah’s first and only completely free HIV clinic.
Both doctors had quickly pivoted to COVID-19.
Emily assumed a leadership role in developing and evaluating therapeutic plans and communicating with the public.
“For better or worse, one of the first drugs considered was hydroxychloroquine,” Emily said. The anti-malarial drug showed initial promise as a treatment, then quickly became embroiled in political controversy.
In late April, the Utah legislature asked the U to investigate the treatment more thoroughly. Adam became co-lead with fellow researcher Rachel Hess on Utah One, a large-scale project studying COVID- 19 patients in their home settings. The data was made available to multiple investigations that looked into questions such as how long people remained contagious, new types of rapid testing, and treatments.
“One of our key findings was that viral shedding might occur up to three weeks following infection, longer than previously thought,” Adam said. “We started the study with hydroxychloroquine and continue to investigate it, but this study is now powering even more research.”
Meanwhile, Emily’s team joined national studies of other treatments, including Remdesivir, an anti-viral that has shown efficacy in treating patients with the COVID-19 infection. “With a new virus like this, every treatment is experimental and should only really be administered as part of a clinical trial. We moved quickly and judiciously to join with other research institutions such as Johns Hopkins, which has helped advance knowledge at the national level and also provided help to our patients here.”
In June, the U set a record for the number of research proposals submitted and, as of September, had received a historic high of more than $600 million in research funding.
Emily now helps to lead the evolution of therapeutic protocols, in coordination with Mayer, Hatton, and teams across the university.
Even as the worldwide pandemic consumed their professional lives, the Spivaks tried to maintain balance at home. “We have three young children, and we had to figure out ways to work from home,” Adam said.
“I feel like we help maintain one another’s perspective,” Emily added. “We live and breathe the data of COVID, but we’re also experiencing this moment as a family. Just like everyone, we want to get the world back to normal. That’s what we’re fighting for.”
LETHAL COMBINATION
As Utah entered the third month of lockdown, unrest began to simmer.
The steady and relatively low average of case counts meant that COVID-19 had not yet directly impacted the lives of most people within the state; but the economic effects of the shutdown certainly had. Unemployment in the state had spiked from 2.5 percent in January to 10 percent in April. Most of the job losses disproportionately hit those with lower incomes.
Persisting social isolation also began to affect mental health significantly. Extended families were unable to visit with one another as people cocooned in their homes. Restaurants, bars, coffee shops, and entertainment facilities remained closed to indoor seating. For many, loneliness, uncertainty, and real economic hardship began to exact a toll. Call volume to the Huntstman Mental Health Institute’s crisis lines increased by almost 25 percent in May. Salt Lake County police reported similar increases in calls for domestic violence.
Governor Herbert tested the waters to loosen restrictions, but the people of Utah did not wait for an official announcement. Over Memorial Day weekend, tens of thousands headed outside to enjoy warming temperatures. For many, it was a much-needed opportunity to reconnect with one another and enjoy a sense of lost normalcy. Health experts at the U and across the country warned that the world was not out of the woods and that COVID-19 remained a present threat—but as frustrations continued to mount, the warnings went unheeded.
THE NATION SHOOK
On Memorial Day, a video circulated showing George Floyd, a 46-year-old Black American, killed during an arrest in Minneapolis. The incident was yet another in a series of deaths of Black men and women at the hands of the police.
Anger over longstanding inequities and racism collided with the pandemic. Protests in cities across the country flared, including in Salt Lake City. People rallied in front of the capitol chanting “Black Lives Matter”— echoing a phrase that came to define a movement.
“COVID did not cause the protests. But health inequalities are a significant part of societal inequalities. We cannot discuss the pandemic without dis- cussing the Black Lives Matter movement. The two are now intertwined,” Rodríguez said. The fact that the mass congregations might have made the participants vulnerable to the spread of the virus only showed how important the cause was. “Some discussions need to be had—even if they come with a price.”
THE FIRST WAVE
Immediately following Memorial Day weekend, and before the protests took hold, cases in Utah and other states in the Mountain West began to rise.
Case counts, which had yet to break 200 per day, more than doubled in June. Neighboring states throughout the Mountain West saw a similar rise in cases, with Arizona being the most dramatic.
“For the first months, we had in many ways been lucky,” Pendleton said. “We had time to watch what was happening in other regions such as New York and prepare. Now our turn was beginning.”
The U opened its new dedicated COVID-19 wing, named B-50, just in time to receive an influx of new patients.
“Thankfully, we knew more about how to treat the disease,” Spivak said. “In March, there was a rush to put patients on ventilators quickly if they developed breathing problems. We now know that techniques such as proning [placing a patient in a facedown position, lying on the abdomen] were more effective. We also had Remdesivir. So, while cases were going up, mortality rates were at lower levels than what we saw in New York.”
But hospital leaders kept a wary eye on the state case counts. Based on their estimates, an infection rate of 700 or more cases per day would translate into a need for more staffed hospital beds, especially ICU beds. On July 9, the daily new coronavirus case count was nearly 900.
U of U Health, Intermountain Health Care, and other hospitals pushed a new campaign encouraging the observance of precautions, and the public seemed to respond. Late July and August were characterized by stable, low levels of virus transmission. The first real wave in Utah, it seemed, had abated.
Hatton and his team breathed a sigh of relief. “For a moment, things looked like they were backing off.” The respite, however, proved to be short-lived.
THE SECOND WAVE
With cases stabilizing at the end of August, some schools across the state began to reopen, including the University of Utah. Businesses experimented with more working hours. Family gatherings, which could be held outdoors during the summer, began to take place inside homes. A sense of general COVID fatigue crept into the public sphere.
Some have theorized that the final months of the election season also impacted efforts to contain the virus.
On October 7, the University of Utah served as center stage for the conflict over the nation’s response when Vice President Mike Pence and Senator Kamala Harris squared off for the Vice Presidential Debate. Just four days before, President Trump had been diagnosed with coronavirus and was admitted to Walter Reed Medical Center for treatment.
Experts traced the infection of Trump and other senior officials to a ceremony announcing Amy Cohen Barrett’s nomination to the Supreme Court. The event was invitation-only and amongst trusted colleagues, so attendees felt safe enough to interact without masks or social-distancing. The conditions were ripe for infected individuals to shed the virus at high levels.
At the debate, screens were placed between Pence and Harris—a visible marker to the entire nation that the virus was not abating.
The circumstances of the White House ceremony— which became known to researchers as a “super- spreader” event—were similar to the ways that the virus spread throughout Utah and the Mountain West. Data began to show that schools, businesses, and restaurants that observed ordinances were less likely to become places of infection. Instead, as contact tracers investigated the rise in cases, they discovered that gatherings of younger people aged 15-24 and large family events where guards were dropped were the new loci of transmission.
On the U’s campus, infection rates have been relatively less severe thanks to a robust set of protocols. As of the first week of November, there have been 1,267 cases, between 2 and 3 percent of the campus community. The daily case counts across the state were startling. In October, they rose above 2,000, more than triple the highs of the summer, and within weeks jumped to 3,000.
This prompted Governor Herbert to make major changes to the COVID-19 guidelines, creating a new transmission index to determine which ordinances would be required in each county with the help of local health leaders. Then, on November 8, Herbert issued executive orders creating a new set of restrictions including the statewide mandatory wearing of masks, and a two-week restriction on social gatherings outside the home, with fines of up to $10,000 for violations.
“We need our doctors and our nurses,” Herbert said. “And now they are pleading for our help.”
PREPARING FOR THE NEXT YEAR
“Vaccines have been developed, but we’re only just now figuring out how to distribute them,” Mayer said. “There will be a race to produce enough for the world’s population.”
And yet there is hope.
In the fog of war, there are said to be three types of knowledge: “known knowns,” information that you are sure of; “known unknowns,” information that you don’t yet have and seek to learn; and “unknown unknowns,” that which you don’t even see coming.
A critical aspect of the fight against the disease has changed: It is no longer a surprise. COVID-19 is no longer an unknown unknown.
“When we started this journey, we didn’t know anything about the virus, the disease it caused, or what would be required to treat it. Today, we’re more sophisticated,” Pendleton said. “We know that surges will come and go. And we know what parts of the hospital we can convert to expand capacity. That doesn’t make it easy, but with the help of the people of Utah... we know what to do.”
Importantly, we also defined the contours of what we have yet to learn. Perhaps our most significant victory is that we now know what we don’t know.
“We are at a very challenging juncture,” said President Watkins. “To the degree that we are able to combat COVID-19, it is thanks to the coordination of our talented team. Our university, state, and the Mountain West region owe a debt of thanks to University of Utah Health.”
“Everyone here has risen to meet this challenge, and continues to make enormous sacrifices in this fight,” said Good. “From the frontlines of care to the laboratories and the makeshift home offices, our caregivers, support staff, faculty, students, and associates have all demonstrated bravery, creativity, and compassion. I could not be more proud to work with such an exceptional group.”
But the effort will take all of us. Good reflects back on the masks he noted on the faces of an audience watching figure skating, “We have changed a lot as a society since then. We can—and must— learn to live with this disease. We still have a great deal of work ahead of us. I know that we will continue until the final chapter is written, and we can say that we have won.”
Until then, we continue the fight.