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Learning and Adapting as the Covid-19 Pandemic Evolves

Delivering supplies, distributing aid, and tracking data have taught Direct Relief a lot about responding to a pandemic.

More than 1,000 shipments of protective gear are prepped for shipment in Direct Relief's warehouse on May 7, 2020, in response to the Covid-19 outbreak. (Lara Cooper/Direct Relief)
More than 1,000 shipments of protective gear are prepped for shipment in Direct Relief's warehouse on May 7, 2020, in response to the Covid-19 outbreak. (Lara Cooper/Direct Relief)

Direct Relief CEO Thomas Tighe recalled, in Covid-19’s early days, a formative virtual meeting with the director of a major Wuhan Hospital – who was dressed in full protective gear throughout. “The palpable anxiety he was exuding was really eye-opening,” Tighe said.

For Tighe, an early indication that Covid-19 might erupt into a history-making event was the simple fact that his organization was asked to provide protective gear and other supplies to China when the outbreak hit. “We had no expectation that we would actually be asked or permitted to help,” Tighe explained. The sheer level of need – from a wealthy country – indicated that there was reason to worry.

That was then.

Since late January, Direct Relief has delivered more than 10,000 shipments across all 50 U.S. states and 62 countries. These deliveries have included a wide range of protective gear, oxygen concentrators and ventilators, and more than 40 million doses of medication.

In addition, the organization has committed $27 million in grant funding to health centers and clinics across the U.S., in an effort to keep safety net providers at work serving vulnerable communities while easing pressure on hospitals and public health departments.

At the same time, Direct Relief analysts have been at work producing a series of data tools designed to inform policies and decision-making. Their work has been drawn upon by state governments, including that of California, to guide stay-at-home orders and other policies.

During a May 11 webinar, Tighe, along with pharmacist Alycia Clark and vice president of Research and Analysis Andrew Schroeder, discussed the guiding principles that have informed Direct Relief’s response thus far, and what the organization has learned from nearly four months of aid delivery, funding, and research.

Protect the Safety Net

Direct Relief’s staff was already well aware of the vital role that the U.S.’s free clinics and health centers played in managing chronic conditions, thus easing pressure on hospitals and keeping vulnerable people from needing to visit the emergency room – which might otherwise be the only health care option available to many.

“We really wanted to make sure that they stayed functioning,” Tighe said. “The ripple effect of them not being able to function because of PPE…would have rapidly exacerbated pressure on the hospitals.”

A shipment bound for International Community Health Services in Seattle, Washington, leaves Direct Relief’s warehouse on March 10, 2020. The shipment contained more than 400 pounds of protective gear, including surgical masks, N95 masks, gowns and gloves, for the health center’s staff, who are continuing to provide primary care as the city works to contain the coronavirus outbreak. (Lara Cooper/Direct Relief)

But as Covid-19 gained ground in the U.S., the resiliency – and vulnerability – of these safety net providers became increasingly clear.

For one thing, health centers and clinics, like everyone else, were dealing with a frightening shortage of PPE. Staff were concerned for their own safety. Cases of Covid-19 broke out at some health organizations.

In addition, safety net providers already operated on shoestring margins. The revenue lost during Covid-19, as people hunkered down at home, sometimes letting health conditions go unmanaged, forced some to close their doors.

Clinics, many of which depend on volunteers, lost much-needed staff or asked providers – many of them retired and of high-risk age – to stay at home. Some health organizations were forced to let go of health care workers, placing more pressure on those that remained.

But at the same time, many of these same providers quickly made the transition to telehealth, allowing them to keep tabs on vulnerable patients while protecting staff and volunteers. Others have moved to home visits, curbside drop-offs, and even delivering food supplies as food insecurity has risen in their patient populations.

In addition, health centers and clinics have stepped up to do some of the work previously managed primarily by hospitals and public health providers. They’ve done Covid-19 testing – sometimes in patients’ cars or under tents in the parking lot – and conducted vital contact tracing. Some even have fielded 911 calls, Tighe said.

And safety net providers have proven vital in disseminating public health information, such as the importance of stay-at-home orders. “They’re well trusted, that’s kind of their stock in trade,” Tighe said. “They deal with people who need to trust and internalize the public health messaging that’s going on.”

Think Ahead to the Next Need

PPE has been an urgent need since the early days of the crisis and procuring and dispensing it has been a major focus at Direct Relief.

But even early on, Clark, a pharmacist with a background working in hospitals, was thinking about what might come next.

At the time, five percent of patients were becoming so sick that they required ICU care. Clark knew that meant an increased need for intubation and sedation, and increased rates of pneumonia and sepsis.

So she developed a calculator to figure out how much of vital medicines and supplies would be needed to manage the most severe case. “We had to make our best-educated guess,” with input from medical experts.

Direct Relief developed 500 “push packs,” each containing enough medication and supplies for 100 hospitalized patients.

Medicines essential for ICU care of Covid-19 patients are prepped for shipment in Direct Relief’s warehouse on April 24, 2020. The modules contain medicines needed to care for complications of Covid-19, including bacterial pneumonia and septic shock. (Lara Cooper/Direct Relief)

Although the organization had well-established relationships with safety net providers, working with U.S. hospitals was a new endeavor.

Collaborating with the American Hospital Association and the Society for Critical Care Medicine helped Direct Relief build relationships and identify hospitals that more urgently needed help.

Hospitals “were using the medications the very same day they were receiving the push packs,” indicating a far more acute shortage than was widely acknowledged at the time, Clark said.

“Flattening the Curve” Doesn’t Mean Everywhere

Schroeder explained that, while the U.S. had ostensibly flattened its curve in early April, and had stayed at a plateau since that time, “the more you turn a prism on it, the more you see the nationalization of the epidemic.”

Schroeder pointed to new cases in Texas, Virginia, and Illinois as examples of the disease’s ongoing transmission. “That flat plateau we’re at contains a lot of variation across the country,” he said. “A lot of plains states and the south have come online as some of the fast-growing areas of the epidemic.”

Social distancing – one of the only tools we have to control the spread of the pandemic – and caseload are increasingly clearly tied together, Schroeder said. The areas that have had the hardest time maintaining social distancing are also the ones seeing a worrisome and growing caseload.

As an example, Schroeder turned to his home state of Michigan, where the northern, more rural areas of the state have seen a recent increase in mobility. “They’re back exactly where they were at the moment when these policies were implemented,” Shroeder said. These same areas are among those of concern.

In response, Schroeder suggested, policymakers might focus on “policies and practices most likely to support those communities where it’s just hard to socially distance.”

Direct Relief CEO Thomas Tighe delivers masks to essential workers in Goleta and Santa Barbara on April 28, 2020, during the Covid-19 pandemic. (Lara Cooper/Direct Relief)

Adapting to a changing pandemic is a changing process. For example, Tighe said, at one point Direct Relief, working from the information currently available, assumed that a major hospital would request to be supplied with ventilators.

Instead, the doctor they spoke to requested portable oxygen concentrators, which would allow people recovering from Covid-19 to convalesce at home. “’We have to get people out of the beds,’” Tighe recalled him saying.

Overall, “I think each piece of the response has informed the next one,” Tighe said.

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