April 29, 2020
By Deborah O’Neil
Clinicians and health system leaders worldwide are learning day by day through trial and error how to treat COVID-19 patients while keeping themselves safe from infection. The work is risky, frightening, and uncharted.
With expertise in global public health and pandemic response, Ariadne Labs has strategically focused its teams of clinicians, public health researchers, and data scientists to develop, test and disseminate the most effective clinical practices based on the best available data. A joint center of Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health founded in 2012 by Atul Gawande, Ariadne Labs was among the first organizations supported by the Patrick J. McGovern Foundation to address COVID-19.
Recently, Ariadne Labs Executive Director Dr. Asaf Bitton took time to talk about COVID-19. A primary care physician who
also worked on pandemic preparedness after Ebola, Bitton is both leading Ariadne Labs’ large-scale response and treating patients through his Brigham clinic. “We are awash in this crisis. Most calls are about COVID-19 or symptoms that might be COVID-19,” he said. “But health care doesn’t stop. People still have heart attacks and asthma flares and appendicitis, and it is all that much more difficult.”
In this second of a two-part interview, Bitton outlines the COVID-19 work of Ariadne Labs.
Can you map out how Ariadne Labs has ramped up to respond to COVID-19?
From the first reports of an outbreak in Wuhan, Ariadne Labs had been watching COVID-19’s development extremely carefully. As the leader of the organization, my top priorities were to be ahead of the curve, protect our staff, and keep functioning. We were among the first health care organizations in Boston to ask staff to work remotely. And we were able to do that because we had been anticipating COVID-19’s potential impact in Boston for weeks.
Our mission at Ariadne has always been to develop simple, scalable solutions that dramatically improve the delivery of health care at critical moments to save lives and reduce suffering. COVID-19 has become a critical set of moments in everyone’s lives, and it was clear to us that Ariadne had an important role to play.
Our core strengths are that we are able to quickly convene, converge, gather best practices, design and test guidelines and tools, and then spread them as widely as possible through the many channels available to us. Practically overnight, we created a framework built around our clinical areas of expertise to focus the organization on developing COVID-19 solutions that would draw on new research, front-line experience, and Ariadne’s resources and accumulated knowledge.
What are the focus areas of the work?
The first are community mitigation strategies. We are concentrating on communicating simple, practical, evidence-based information for the general public to apply in real-life scenarios. For instance, addressing how do you practice social distancing, such as the advice featured in my This is Not a Snow Day piece, and how do we protect health care workers to limit transmission. What are the other strategies that a community needs to take to protect itself? We’re also analyzing the responses from other countries to identify and disseminate key lessons from global community mitigation strategies. These involve harvesting best practices from positive outliers, as well as lessons learned from countries struggling with overwhelming numbers of infections.
The second concerns a global response. COVID-19 is a worldwide crisis and the situation calls for a global response, from studying how other countries have responded to developing tools to equip and enhance the global health workforce. Through interviews and a review of protocols and available data, we are currently developing case studies of how countries such as Japan and South Korea have responded to the pandemic, in addition to formulating guidelines for low- and middle-income countries in their response. Additional projects include working on identifying digital tools to support health care workers across the world and formulating a framework for vaccine delivery that is both effective and distributed equitably.
The third area is about care for adults over 65 and vulnerable populations. Adults over 65 years of age and other vulnerable populations are disproportionately at risk from COVID-19, and many may also be challenged by social isolation, loneliness, and the lack of support and resources. How do we keep them from being socially isolated? How can we continue services? We have also been working on new guidelines for serious illness conversations during the pandemic, and how we can structure supports for this important community.
The fourth area is obstetrics. We are studying ways to provide the continuum of obstetric services, from prenatal, labor and delivery, and postnatal services, when clinicians are at strained capacity and both they and their patients are at personal risk. As the data continues to shift, we are asking, what are we learning about vertical transmission, and the risk of transmission during delivery? How do we restructure and reshape so much of our work on Expecting More, which aims to narrate a dialogue on dignity, and reframe it in light of the COVID-19 crisis?
The fifth area is safe surgery and systems. The strain that COVID-19 has placed on health care systems has had immediate and consequential effects on hospital surgeries and procedures, physician capacity, and redeployment, and the onboarding of physicians rushed into service. We’re developing resources to address all of those areas, such as the recent protocols that were published in the Annals of Surgery on how to cancel elective surgery.
Finally, the sixth area has been outpatient care, specifically, the virtualization of primary care and ambulatory care. Even during a pandemic, there remains a need for people to have safe, reliable access to outpatient medical care both for COVID-19 related illnesses and for medical needs unrelated to the virus. We are developing resources for patients and providers, such as principles for effective virtual and telehealth.
What experience and expertise does Ariadne Labs bring to those focus areas?
Our organization’s expertise – rooted in evidence-based, front-line experience and our previous work creating systems-level tools to address gaps in health care delivery have quickly positioned us as a leading voice on best practices and guidelines in addressing COVID-19. We have a wonderfully diverse and eclectic mix of talents, skills, and expertise, enabling us to quickly develop significant assets and prototype and test new innovations in most of our priority focus areas. I am so proud and humbled by the strength of science, innovation, implementation, and communications expertise that our teams have leveraged to quickly formulate sound, scalable products, and to amplify the voices and ideas of our clinical and scientific leaders.
What kinds of tools, guidelines and perspectives are you creating?
Keeping in mind that the world has only had about four months of combined experience with this disease – there is no specific playbook yet, but every day we learn more about it. That said, we’ve been able to rapidly create consensus guidance on practical, clinical, and organizational matters for hospitals and health systems that are already being used around the world.
Addressing the needs and concerns of seniors and vulnerable populations, our Serious Illness Care Program developed The COVID-19 Response Toolkit, to support health systems and clinicians in addressing the communication needs of patients in the community and those in the hospital. The toolkit also includes resources for patients to begin having these conversations with people they trust within their support networks.
As we begin to develop our Global Response work, we’ve already had faculty, such as Dr. Rebecca Weintraub, publish their perspectives advocating for why a vaccine will need equitable and global distribution.
There is a much-needed debate taking place in the field of obstetrics and Dr. Neel Shah has provided commentary on not only the chaos and confusion that pregnant women are experiencing, but also recommendations for expecting mothers and acknowledgement of the “shaky data” that clinicians are working with as they make life, death and quality of care decisions.
In addition to our general social distancing guidelines, we created guidelines specifically for families with school-aged children. We’ve offered our perspective on how to address the growing shortage of personal protective equipment and outlined guidelines for surgical systems to manage their response.
The group working on safe surgery and systems has already released strategies addressing the growing shortage of personal protective equipment, guidelines for how hospitals can empathetically implement zero-visitation policies while still providing effective patient and family-centered care, and reflections on the impact of zero-visitor policies on patients in the ICU.
Our outpatient care team has released recommendations for how patients should obtain primary care through virtual and telehealth options in the coming weeks and guidelines for how pediatric clinics can continue caring for children without potentially exposing them to virus via in-person visits.
In the next few weeks and months, we will be releasing a case study on how South Korea has been safeguarding its health care workers amidst the pandemic and telling the story of the incredible global collaboration that made the research possible, conversation guides for patients in nursing homes, training aid in the training of new health workers, guidelines for everyday activities, such as safe grocery shopping, and more.
Ariadne Labs worked on both the H1N1 and Ebola crises. Are there any lessons that apply to this particular pandemic?
Ariadne Labs is no stranger to pandemics and through those experiences, we’ve learned significant lessons – both good and bad. For instance, we know coordinated, unified, science-first, fact-based responses work. They work when governments convene experts, listen to data, take proactive steps, and move with urgency and coordination to mitigate a pandemic crisis. They don’t wait for perfect data; they make best guesses, and they often need to assume the worst in order to prevent the worst.
Our work in Ebola was about quickly putting together “good enough” protocols on infection control, with the CDC and other bodies. We really assumed that it could be in every hospital, so these protocols needed to be disseminated as quickly as possible in a coordinated, unified channel. The level of urgency of discussion, even at that time when Ebola was “only” in three countries, exhibited a seriousness of purpose, that, quite frankly, I wish we had replicated in this setting.
On the flipside, we’ve learned that when you don’t have this unified approach but instead see fragmented, state-by-state, city-by-city response, it’s not as effective. Viruses don’t respect borders. They don’t care about politics. They’re just 30-some odd genes that want to infect your cells.
I remember in the wake of Ebola in particular, so many multinational bodies – in the U.S. and in other countries – promised to ensure that our global response to pandemic preparedness would be better. They promised to invest in responsive health systems that were integrated with public health to ensure this wouldn’t happen again.
And yet, the response to COVID-19 has been worse. I can’t tell you how frustrating that is, on so many levels. We should have known, and yet we dismantled the very apparatus that we needed to be ready for this, and we’re now paying a heavy, heavy price for those decisions.
Do you have a sense yet of what needs to change for the future?
My hope is that when the pandemic is under control, we will avoid the usual form of human amnesia about these collective traumas and the risks they pose. Because, the reality is that there will be another pandemic. The question is, are we going to respond differently and more effectively? We need to ensconce and concretize our learnings and these remembrances into our future actions. Otherwise all of this is just for naught.
That’s why our work at Ariadne is so meaningful. When all this is done, we will have documented our tools, protocols, and lessons learned and have them ready to present to the policymakers we work with, the influencers we’re in touch with, the health system leaders, and the public. We will use our voices as trusted clinicians and scientists and advocates to say, “These are the lessons. There’s now a playbook here, and it’s not that complicated. Use them, and don’t forget about them when it’s not convenient to think about it. And we will save lives.” That is Ariadne’s abiding goal.