Our clinical practice is located in New York City (NYC), New York, the global epicenter
of coronavirus 2019 (COVID-19). At the time of this writing in early July 2020, there
have been over 222,000 cases and nearly 23,000 deaths in NYC in the 3 months ending
in June 2020. As of early June 2020 we have managed 65 patients with IBD and confirmed
SARS-CoV-2 diagnosed by PCR-RNA for the virus (48 patients), by positive IgG antibodies
(17 patients), and by classic COVID-19 presentations. As of June 2020, the number
of cases from this practice exceeds the number of cases reported from of any state
outside of New York in the United States and exceeds the number of cases in 43 of
the 47 countries reporting to the international SECURE-IBD registry of patients with
IBD and SARS-CoV-2infection.
1
In this article, we share our real-world experience in the care of this large cohort
of patients, describe our practice’s approach, and offer suggestions to the practical
care of the patient with IBD and COVID-19. We also hope to describe the sense of life
in NYC at this uniquely tragic time. Through the month of June, NYC had successfully
passed through “Phase 1 of reopening,” allowing most businesses to open with appropriate
“social distance” and wearing of masks both indoors and outdoors. This followed a
3-month period of onerous and suffocating but effective shutdown of NYC. But by early
July, some plans to further reopen NYC were abruptly halted by the recognition of
major new outbreaks in states such as Arizona, Texas, and Florida, where statewide
closings came too late and reopening occurred too early. This has led, almost predictably,
to a foreboding spike in cases, hospitalizations, ICU admissions and deaths into August
2020, in a pattern resembling the onset of the most ominous weeks in NYC in March,
April and May. As the number of cases is now growing alarmingly throughout other areas
of this country and around the world, we hope that sharing the lessons that we have
learned to date will be of value to others.
Our extensive experience in caring for IBD patients with COVID-19 stems from our practice
in which we have a very large IBD patient population of Ashkenazi Orthodox and Hasidic
Jews that comprises nearly 75% of our cohort. Our observations and those of others
have been that these groups most likely have the world’s largest incidence of multiplex
IBD families (Dubinsky, personal communication, May 30, 2020), and outside of Israel,
they are located in greatest prevalence by far in New York City. Many of these families
have large numbers of children (more than 8 is not uncommon), and many live in crowded
apartments or homes. Socially, they tend to be insular and very tight-knit communities,
and there are several areas in New York City (Williamsburg, Borough Park, New Square,
Monsey, and Kiryas Joel) and in New Jersey (Lakewood) where several thousand families
can live within walking distance of each other. Families attend weekly Sabbath and
holiday services in often crowded synagogues and share attendance at many large communal
holiday gatherings, weddings, and funerals. Large clusters of cases arose at some
of these events. The close contact source of infection in these communities is suggested
by the finding that over 80% of these patients in our cohort can identify household
members with SARS-CoV-2 (with anywhere between 1 to 8 family members affected), whereas
patients in our cohort from outside these communities have known household contacts
of only approximately 30%. The stunningly abrupt, chronologic tipping point in these
communities was clearly on March 10, 2020, on the Jewish Holiday of Purim. The holiday
is marked by a great deal of celebratory dancing, communal meals, and near universal
delivering and sharing of gifts and delivery of food between families. Within 1 week
of this holiday, the onslaught of cases, severe illness, and death began in these
communities.
Because we advised our patients to stay at home isolation if they had typical symptoms,
the great majority of our patients who tested positive for PCR of SARS-CoV-2 either
had another physician order the test or tey had obtained it on their own. We had only
selectively ordered PCR testing in the very first weeks of the pandemic when the disease
course and presentation was less well described. More recently, most patients who
were tested for SARS-COv-2 antibodies were being tested if they were otherwise going
to have labs drawn. In some of these communities, both the Mayo Clinic and the Mount
Sinai Medical Center put out calls for volunteers, and over 2000 subjects presented
to be tested for the SARS-CoV-2 antibody in the hope of being able to donate plasma
for potential use for convalescent serum as treatment for patients infected with SARS-CoV-2.
In this report, we share our experiences and suggestions in the management of patients
with IBD, in addition to SARS-CoV-2 and COVID-19 patients in a clinical outpatient
practice.
The Scene in NYC in March, April, and May 2020
On March 1, 2020, a woman recently returned from Iran, where the disease was already
widespread and was diagnosed with the first case of SARS-CoV-2 in NYC. The following
day, a 51-year-old attorney living in New Rochelle (a suburb 5 miles north of NYC)
who traveled daily by train to his office in Manhattan was diagnosed without any known
exposure. Within a single week that index case led to a cluster of over 120 in his
home community of New Rochelle, which then became the first community in the United
States to become an enforced “containment area”; the National Guard briefly patrolled
the streets, not to quell civil unrest but to assist in food deliveries and to provide
the personnel to disinfect public areas. The first death in NY was reported on March
5, and then began an unfathomable, exponential explosion of cases, hospitalizations,
and death that shook and devastated NYC. In the 4 months since the first case, NYC
has become the global epicenter of COVID-19, with over 222,000 reported cases leaving
nearly 23,000 dead.
3
To put this into context, this number represents greater than 7 times the number killed
on September 11, 2001 in the World Trade Center attacks.
The unrelenting, massive torrent of patients overwhelmed NYC hospitals, intensive
care units, and staff. Overall, 1 in 37 individuals tested in NYC were positive, and
1 in 360 residents of NYC died.
2
East New York, an urban area with an almost entirely black and Latino population,
with a median annual household income of $27,000, had the highest death rate in the
city: 1 in 23 residents were infected and 1 in 141 residents of that area died of
COVID-19. Citywide, the death rate of blacks and Latinos was twice that of white residents.
Major medical centers in NYC such as Mount Sinai and New York University would be
managing over 1000 COVID-19 patients at once, and lobbies were converted into patient’s
rooms, and operating rooms and postop recovery areas into intensive care units. Massive
refrigerated trucks serving as overflow morgues were parked outside some of NYC’s
municipal hospitals that serve the city’s most impoverished patients. Samaritan’s
Purse, a charitable rescue-mission organization, arrived on a Saturday night, March
28, and by that Tuesday had set up 6 cavernous medical tents equipped to handle 300
overflow inpatients on the pastoral lawn of Central Park directly across the street
from Mount Sinai (see Figs. 1 and 2). Inside Mount Sinai, “platoons” of medical teams
were deployed in sequential waves of attendings, fellows, and residents. Early on,
there were variable appalling shortages of personal protective equipment (PPE), further
heightening risk to the staff. In some of the most deprived municipal hospitals, staff
with direct patient care were told to wear rain ponchos in lieu of proper gowns. A
number of hospitals imposed gag orders on their staff from speaking to the press about
ongoing PPE shortages.
FIGURE 1.
In foreground, Mount Sinai Annenberg Basic Science Building and Icahn School of Medicine
(taller building) and The Guggenheim Pavilion of the Mount Sinai Hospital. On right,
fully equipped and staffed Samaritan Purse hospital tents for 300 overflow patients
on Central Park lawn. For the hospital, note white paneled wood windows with open
carved-out “portholes” for negative ventilation to outdoor air (photograph courtesy
of the author, April 7, 2020).
FIGURE 2.
Nighttime view of Mount Sinai Hospital, Samaritan Purse hospital tents, and views
of the iconic Central Park Reservoir and Central Park skyline (April 13, 2020, photograph
courtesy of the author).
Each of our gastrointestinal (GI) fellows served on the COVID-19 floors for multiple
rotations at Mount Sinai and thus denying them of months of training. Early on, we
each volunteered to be on call for inpatients with GI bleeding to relieve the fellows
physically and emotionally, reduce additional COVID-19 exposure risk for them, and
save on PPE in that only the attending would be present during a procedure. Frankly,
we were relieved when our nights and weekends of being on call passed without any
patients requiring emergency hospital procedures. In NYC, a number of physicians,
nurses, and residents contracted the virus and were hospitalized, and a few among
them died.
Outside the hospitals, the 5 boroughs of NYC, home to 8.2 million residents, were
put on “lockdown” on March 22. The boisterous, rambunctious, often ornery, and cantankerous
city overwhelmingly observed all designated social prohibitions. The city became eerily
silent overnight, with all nonessential businesses shut down, with many likely never
to reopen. Unemployment soared and 900,000 NYC residents became unemployed within
a space of 2.5 months. At its worst, at midday one could drive down entire ghostly
avenues and streets devoid of any people outdoors. Nonetheless, the prevailing mood
was of mutual camaraderie, support, and empathy. Many local restaurants delivered
daily free meals to the hospital’s entire medical staff. The sacrifices of the health
care workers and first responders did not go unnoticed. They were loudly lauded and
appreciated throughout the city on the (nearly empty) streets and in the media. At
7:00 pm nightly, many New Yorkers stepped out onto their stoops, their sidewalks,
and their balconies and applauded all the first responders of NYC.
Office Practice Management of an IBD Practice in NYC
Though the physicians in our practice all hold academic faculty positions at the Icahn
School of Medicine at Mount Sinai, our clinical practice is run independently of the
Medical Center, and thus we are faced with all of the management, financial, and personnel
issues of any “private practice.” With the loss of income from a decline in office
visits, greatly reduced procedural volume, and loss of income from a partial ownership
in an ambulatory surgery center (ASC), we benefitted greatly from receipt of a Paycheck
Protection Plan (PPP) loan, and all provisions were made to fulfill all stipulations
to ensure loan forgiveness in the future. Frankly, absent this grant, the financial
strain on the practice would have been prohibitive, given our commitment to the staff
and the typically very high costs of maintaining a practice in Manhattan (monthly
rents can approach $100 per square foot). Nevertheless, the loan is designed to cover
only 8 weeks of expenses, and we are already well beyond that period. Office infusions
of biologics (infliximab, vedolizumab, and ustekinumab) became the main source of
revenue for the practice during that time.
Upon declaration of the NYC shutdown, we immediately made a commitment to our entire
staff that they would remain fully employed for the duration of the crisis, in recognition
of their devotion to the practice for anywhere from 3 months to 28 years. No more
than half of the staff were present in the office on any given day, while the remainder
worked from home, and the staff area is situated in a fashion that all staff, wearing
masks, are at least 6 feet apart. We made (variably successful) efforts to avoid having
all staff present in the office on any given day in case there were an office-wide
exposure to SARS-CoV-2.
As with all other gastroenterology practices, “telemedicine” has replaced the vast
numbers of office IBD consultations and follow-up visits. We have termed these as
Video Office Visits or Telephone Office Visits for our patients. We wanted to avoid
the term “virtual,” which could give the connotation that these visits were virtual
rather than real, and we avoided the generic term of “telemedicine” because this term
has been used to describe a variety of forms of remote care. The volume of consultation
and follow-up visits was approximately 70% of our usual number, as would be expected
in a practice caring for a large number of chronic patients with IBD. We have found
that nearly all of our patients found these visits worthwhile and would opt for remote
visits in the future for some or many of their routine follow-up visits. On the other
hand, the well-described “Zoom fatigue” set in rapidly and largely negated the hoped
for “leisure” of working from home several days a week.
As with most other GI practices, we performed a very small number (ie, about 5%) of
our usual number of procedures in an ambulatory endoscopy setting. These were done
for disease assessment in patients with severe disease for whom a change in therapy
was being planned or for patients who required stricture dilation. Meticulous care
and great efforts were taken to secure adequate PPE, and all cases were done fully
gowned, with N95 masks (one per day), eye protection, and full face shields. Rooms
were equipped with air filtration devices, and 30 minutes were spent between cases
disinfecting the endoscopy rooms.
A Clinical Visit
The video visits, as in real life, consist of a dialogue with our patients, and we
have largely avoided sending patients out for labs of any type. However, we have increasingly
relied on commercial labs to send an overnight home stool collection kit for calprotectin
that can then be picked up by one of the express mail services eliminating the patients’
need to leave home. Imaging studies have likewise been largely deferred except for
the patient with a bowel obstruction or concern for abscess. The patient with a perianal
abscess may be a tough call to make. An on-screen demonstration of a perineum is often
less than optimal, and we have some of these patients go straight to a colorectal
surgeon for a video visit and examination under anesthesia if an intervention is thought
to be necessary. We deferred all routine screening and surveillance colonoscopy, any
planned follow-up procedures to assess for routine response to therapy, and the 6-month
postoperative ileocolonoscopy to assess for Crohn’s disease (CD) recurrence. Refreshingly,
we have relearned what our beloved mentor, Dan Present, would say in his inimitable
Brooklyn accent, “If you wanna know how a patient is doin’ all you need to do is say,
‘how you doin’?” Depending on old-fashioned clinical judgment has never seemed as
reliable as it is now.
A significant portion of each visit at this time is spent describing what we know
on that given day about COVID-19 and the interface of COVID-19 and IBD. We preface
these remarks by informing patients that this information is accurate as of the day
and hour of our discussion because frequently our knowledge has changed by that afternoon
or evening.
We have communicated with our patients in a variety ways. Our electronic medical record
allowed us to generate email blasts to our entire practice. The first of these, in
late March, described the general symptoms of COVID-19 and the importance of adhering
to all the risk mitigation programs at that time, which have since then been further
expanded. We described the possible GI manifestations, chiefly nonbloody diarrhea,
and asked patients to contact us with these or any other GI symptoms. We discussed
that in general, our IBD patients should not discontinue their medications but should
contact us for individual recommendations. Also, our email informed them that they
should contact us to discuss whether any routine follow-up labs should be deferred,
which we most always advised. A second email in late May reviewed the emerging nature
of our knowledge of the disease course, and the role of both repeated PCR and antibody
testing—topics which are now evolving on a weekly or even daily basis. A technique
that we have found helpful is to place relevant educational information in an “away
vacation” message that is generated with every routine patient email to us, which
they would see along with our email reply. The chief source of information to which
we directed the patients were the websites of the Crohn’s & Colitis Foundation and
the Center for Disease Control (CDC).
Medical Management of the IBD Patient With SARS-CoV-2, Confirmed or Suspected
A number of the major GI societies, the Crohn’s & Colitis Foundation,
3
British Society of Gastroenterology,
4
European Crohn’s and Colitis Organization,
5
The American Gastroenterology Association,
6
and the International Organization for the Study of Inflammatory Bowel Disease (IOIBD)
7
have published guidelines regarding treating the IBD patient with SARS-CoV-2 and COVID-19.
They are largely very similar, and they are concisely compared in a recent correspondence.
8
The key features are that the patient without proven or suspected SARS-CoV-2 should
continue on their current medications with aggressive attempts to reduce steroid usage
because this is the only single agent that has been associated with increased poor
outcomes with COVID-19, defined in the SECURE registry as a composite score of hospitalization,
intubation, or death.
1
Patients are informed that the underlying diagnosis of IBD does not increase the risk
of acquiring SARS-CoV-2 (although this, as with most published recommendations at
this time, has not yet been borne out by rigorous data). In patients with proven or
suspected SARS, it is recommended that all of the biologic drugs, thiopurines, and
methotrexate be held and aggressive efforts made to wean steroids. However, accumulating
data in the SECURE database suggest that patients on antitumor necrosis factor (TNF)
drugs, vedolizumab, and ustekinumab do not have a higher incidence of a poor outcome,
and in fact, patients on theses agents may have a numerically lower incidence of poor
outcomes. On the other hand, the use of combination therapy with a thiopurine and
an anti-TNF drug may slightly increase the likelihood of a poor outcome. In a multivariate
analysis, steroids were associated with a significant increase in poor outcomes, as
were older age and the presence of multiple comorbidities.
9
What has been a consistently surprising finding in the registry is that the use of
mesalamine drugs, even when controlled for disease activity, may be associated with
a worse outcome. Thus far, this has not led us to discontinue these drugs, unless
the patient is already in remission on an anti-TNF drug and the discontinuation of
mesalamine has not been associated with a disease exacerbation.
10
For patients receiving in-office infusions of biologics, we follow the precautions
well outlined in the IOIBD guidance.
8
Patients are contacted in advance of their infusion to ascertain that they have no
symptoms suggestive of COVID-19. They are screened again at arrival to the office,
including a temperature check. The patient must be wearing a mask before entering
the office and must enter the office unaccompanied. Each patient is given their own
wrapped, unopened hand sanitizer to keep and is brought directly into an infusion
room. Unless there is a specific indication for an examination, we remain masked and
conduct our office visit at least 6 feet away from the patient. All furniture and
equipment are washed copiously with bleach between patients. We aim to use so much
bleach that the following patient is struck by its odor and confident that we have
spared no cleansing agent.
We participate in a number of pharmaceutical industry–sponsored, double-blinded, randomized
controlled drug trials. Variable allowances were made by the sponsors to defer in-person
visits, allow remote visits, and lengthen intervals between procedures. In no case
was an elective study procedure mandated during the height of the pandemic between
late March and early June. In any case, the patients and we, on their behalf, would
have refused to do so.
Clinical Outcomes in This Cohort
In our cohort, with 65 IBD patients with a SARS-CoV-2-confirmed infection, our experience
has been of a slightly lower incidence of poor outcomes than in the reported SECURE
database as a whole (4.6% vs 8% respectively), despite a similar median age of 39
(see Table 1). This may be due to having only 1 (2%) patient on more than 10 mg of
daily prednisone compared with 8% of patients in the SECURE registry. The percentage
of our patients on anti-TNF drugs is similar to the most recent report of the SECURE
database (34% vs 29%, respectively).
1
We had 3 patients, with PCR-documented SARS-CoV-2 who were hospitalized for COVID-19-related
complications: a 35-year-old man with ulcerative colitis (UC) on vedolizumab who developed
bilateral pneumonias was intubated and recovered; a 61-year-old man with UC on sulfasalazine
and budesonide who developed adult respiratory distress syndrome was intubated for
3 weeks, and recovered; and a 65-year-old man with UC and pneumonia was treated with
high flow oxygen and recovered. No patients died.
TABLE 1.
Patient Demographics and Medications
Median Age: 39 (range 17–71)
Crohn’s Disease Severity of CD at Time of COVID-19 Diagnosis (n): n = 41
Remission: 46% (19)
Mild: 39% (16)
Moderate: 10% (4)
Severe: 5% (2)
Ulcerative Colitis Severity of CD at Time of COVID-19 Diagnosis (n = 24)
Remission: 42% (10)
Mild: 50% (12)
Moderate: 0% (0)
Severe: 8% (2)
Medications (n):
Adalimumab: 11
Infliximab: 10
Golimumab: 1
Anti-TNF and thiopurine: 1
Vedolizumab: 5
Ustekinumab: 9
Mesalamine/Sulfasalazine: 5
Antibiotics (levofloxacin, amoxicillin/clavulinic acid): 2
Prednisone 20 mg/d and methotrexate: 1
Prednisone 10 mg/d: 1
Upadacitinib (open label in RCT for CD): 1
No medications: 5
Notably, 2 patients with active Crohn’s ileitis, who initially refused hospital admission
because of concerns of being in a hospital with a very high prevalence of COVID-19,
developed acute ileal perforation, and both had surgery (one with a temporary diverting
ileostomy) and had uncomplicated postoperative courses and no COVID-19-related complications.
Another patient on no IBD medications developed severe UC while infected with SARS-CoV-2,
was admitted to the hospital, treated with infliximab and intravenous hydrocortisone,
improved, was discharged, and sustained no COVID-related complications. Two pregnant
patients with Crohn’s disease in remission contracted SAR-CoV-2. The first developed
symptoms from weeks 32 to 38 and had an uncomplicated vaginal delivery at week 40;
she recovered uneventfully. Another patient developed mild COVID-19 symptoms from
week 16 into her third trimester currently and had no adverse outcome during her ongoing
pregnancy now at 27 weeks (Table 2).
TABLE 2.
Outcomes of Interest (Described in Text)
Hospitalizations for COVID-19 related disease: 3
Intubation for ventilation support: 2
Deaths: 0
Pregnancy: 2, uncomplicated
1. Full term uncomplicated delivery at week 40; symptomatic from COVID-19 for 6 days
at week 36
2. Pregnancy ongoing week 24, symptomatic from COVID-19 at 16 weeks for 6 days
Hospitalization related to IBD: 3 (2 CD resections, 1 severe UC treated medically),
all discharged home without developing COVID-19 related complications in hospital
Our concern has been in holding biologic therapy in the patient with active IBD and
SARS-CoV-2 infection. In these patients with resolving symptoms of COVID-19 or with
minor symptoms without fever or dyspnea, we generally continue to treat or restart
early their anti-TNF drug, vedolizumab, or ustekinumab, as long as they are afebrile
without antipyretics for at least 72 hours. The now well-recognized symptoms of loss
of sense of smell or taste can persist for weeks after all other symptoms have resolved,
and we therefore do not consider those patients as persistently infected if they are
otherwise asymptomatic. As a rule, we did not attempt to alter combination therapy
if we were not otherwise intending to do so. In those patients with prolonged interruptions
in their biologics, we consider using a full reinduction regimen, as our greater concern
has been loss of response and the subsequent possible need for prednisone (as occurred
in a single patient); and our greatest fear, now abating, was that patients would
need hospitalization during this crisis when Mount Sinai Hospital had over 1000 COVID-19
inpatients.
We have not typically relied on documenting viral clearance with testing for a negative
PCR or positive SARS-CoV-2 antibody. The ability to document clearance of active viral
infection has been severely limited by problems with availability of PCR testing (now
easing) and the finding of some patients with persistently positive viral PCR, which
in many patients may represent nonreplicating, noninfectious RNA debris.
11
The advent of more widely available SARS-CoV-2 antibody testing is likewise not without
interpretive flaws. One can easily be misled by accepting results from unknown labs,
and we have been very cautious in accepting results of antibody testing without knowledge
of the lab used. Over 130 antibody tests have been brought to the market, many with
absolutely no FDA oversight of accuracy, and as of May 22, 2020, the FDA had only
issued Emergency Use Authorization for 15 of these assays; 13 of 15 had sensitivity
and specificities of >90%, respectively.
12
Many other assays have been found to be entirely unreliable and have been withdrawn
from the market by FDA edict. Even with reliable antibody assays with high sensitivity
and specificity, there is insufficient data at present to know whether the presence
of antibodies are in fact neutralizing, and at what titer—if and for how long—they
may confer immunity.
13
In the absence of either negative PCRs or positive antibodies, we have relied on clinical
resolution of symptoms of COVID-19 for at least for 72 hours as a guide as to when
to restart therapies that we may have held.
A recent IOIBD guidance statement highlights the importance of considering the relative
severity of both the underlying IBD and the COVID-19 course in informing the decision
regarding the timing of restarting biologics.
14
We are now participating in the development of a database that will follow patients
after clearance of the SARS-CoV-2 virus to determine the courses and outcomes of the
IBD and of any sequelae or recurrence of COVID-19 after any drug therapy has been
suspended.
What We Have Learned and Personal Perspectives
Perhaps never in the history of medicine has the advancement of knowledge about a
given disease proceeded with such disconcerting and often terrifying speed. We spend
countless hours devouring the news and ceaseless new published data. We have found
the around-the-clock New York Times online coronavirus coverage, offered free of charge,
15
to be a superb resource—not just for ongoing news coverage and multiple updates throughout
the day on demographics of new cases and fatalities but more importantly for its very
deep reporting of any breaking scientific news in this era when reading a manuscript
from a month ago feels like reading a journal article from the 1950s. The Times and
the Washington Post to a lesser extent
16
have many useful links to articles in press, in the journals, and sites we are the
most familiar with (eg, New England Journal of Medicine, Lancet, Science, Nature,
Johns Hopkins Coronavirus Resource, CDC, FDA, WHO etc., all also offering COVID-19
information free of charge), in addition to online symposia and journals with very
relevant, up-to-the-minute breaking news in clinical trials, microbiology, vaccine
development, epidemiology, public health, and yes, even aerosol particle physics.
MedRxIv is a source of pre-peer reviewed manuscripts jointly established by Cold Spring
Harbor Laboratory, BMJ, Yale. Many important subsequently published papers have appeared
there first, but many manuscripts posted there are never published or subjected to
peer review and so caveat emptor.
17
With the lockdown of NYC in March, the severely limited ability for all to travel,
our greatly reduced in-office staff, and the near closure of our outpatient endoscopy
center, we initially anticipated that our workdays would be shorter. We were mistaken.
Our patients continued to call, many with heightened anxiety regarding coronavirus
and concerns regarding potential interruption in their familiar medical routines of
follow-up care, monitoring, and continued medication treatment. The patients with
ongoing active disease were terrified at the prospect of an emergency room visit or
hospitalization. Patients were particularly grateful for the unsolicited emails we
sent and educational materials we shared with them via the Crohn’s & Colitis Foundation
website, which is always accessible and constantly updated.
We are certain that video office visits will become a staple of ongoing care for routine
follow-up visits and for some patients with mild-moderate flares. Most patients came
to appreciate the avoidance of time and money spent on travel. How and when the payers
rescind their reasonable and enlightened approach to appropriately compensate us for
these visits remains to be seen.
On a personal level, the severely reduced income, the confinement of our kids and
families at home for nearly 3 months, and the constant heightened vigilance we had
to maintain for our staff and ourselves to prevent infection while at work in NYC
amounted to a degree of stress to which we thought we would be immune. We look back
to the outset of all of this, when some of us naively hoped we could contract the
infection, quickly recover and just be done with it. Watching some colleagues fall
quite ill and hearing of deaths of others disabused us of this notion.
Here in NYC, we are hopefully, and perhaps wistfully thinking, that we are permanently
emerging from the era of 3 months that have felt like so many long and very dark years.
It has been a time of unimaginable and unmitigated devastation to our city, with the
poorest blacks and latino individuals in our city, as always, being vastly disproportionately
affected and dying. We have been humbled by our overwhelming limitations in overcoming
what we had anticipated would be just another viral epidemic passing us by and affecting
others less fortunate than us. We hope that while we await the arrival of the “new
abnormal” that the race for effective therapies and the dreamed-of vaccines will arrive
soon enough, that we can learn enough, and be wise enough, to somehow do better for
our patients and for ourselves for now, and for the next tie around.