From emergency room to classroom – the double life of Dr Vinh-Kim Nguyen
Geneva’s Global Health Centre co-director talks about his dual roles leading one of Geneva’s foremost health policy research institutions and battling Covid at the height of the pandemic.
Dr Vinh-Kim Nguyen is accustomed to straddling two worlds – academia and front-line medical work. But those dual roles took on new meaning this year as Nguyen, new co-director of the Global Health Centre of the Geneva Graduate Institute (IHEID), travelled to Montreal during the first Covid-19 wave to treat patients and organize urgent services at Montreal’s first COVID-19 referral hospital in the city, and later in area nursing homes.
A family physician and medical anthropologist who also worked on HIV and Ebola in Africa, Nguyen talked to Geneva Solutions about the importance of treating the “whole” individual and informing health policies from the ground up.
Please tell us more about your experience in Canada as a front-line health worker – which is a pretty unique role for an academic.
I have just never been able to leave clinical practice. I am a doctor. I just love it. And in trying to understand the health issues going on with my patients, anthropology was a more useful lens than epidemiology. As a family physician, the aspect of talking, understanding through stories, and not through numbers, made a lot more sense to me. So, after I fell into an academic career, I always kept up my minimalist hospital career, working 6-8 weeks a year. I was scheduled to do a two-week stint at Jewish General Hospital in early April – a large tertiary centre that is one of the busiest places in Canada. Its clients come from across the city, and include including many recent immigrants from Africa and Asia. Ultimately, I remained for much longer. I spent two weeks helping set up the Covid-19 wards in the hospital, three weeks in the hospital and three weeks in long-term care homes.
And what were your first impressions?
We were the first designated Covid hospital in Montreal, because we had the most negative pressure rooms. The week I started on the Covid ward, in early April, was the week when the epidemic turned from one affecting younger people and travelers to older patients. We started to get the elderly from care homes. As we saw the numbers rising, we soon saw that we would need more beds. So I worked with the hospital to convert regular wards to isolation wards, like for Ebola. We went to about 200 Covid beds, and worked in PPE all day.
The Québec Ministry of Health had a plan to keep mildly ill older people from the care homes out of the hospital. The thinking was that if they went to the hospital, the hospital would be overwhelmed, which was happening in Italy.
The plan made a lot of sense at the time. Mildly ill elderly patients didn’t need an ICU, they needed good, basic supportive care, and so it made sense to try and provide that care in their homes. And yet, as it turned out, the care homes didn’t have the capacity to provide these basic services. I started working on our first Covid hospital ward on a Monday; by Thursday, doctors working in care homes were rebelling. That night 12 ambulances came just from one care home, bringing in elderly patients with Covid.
Soon became very clear to me that the care homes, with hundreds of residents and only 1 or 2 staff physicians, were collapsing. Particularly as the staff all became sick. So, after my stint in the hospital, I went to work at a care home. One place I worked, almost 100 percent of the residents and 90% of the staff got Covid.
What I pieced together was that we had made a terrible miscalculation. We had tried to put into place measures to maintain elderly in care homes, but the homes couldn’t give them the care they needed. In normal times, with 200-300 residents maybe 5 would be ill and require extra care; with Covid that number would go up to maybe 100 people sick. People had to be fed, given oxygen, and put on IVs – and these were not services a care home was set up to provide to so many people. In some homes, up to 90% of residents became infected, and as many as 40% died.
Trying to keep the elderly out of hospital was a terrible, terrible miscalculation, which amounts to a kind of genocide of the elderly, to be frank. Some of these people had survived the Holocaust and now they were going to die of thirst. In the care home where I worked, the staff was just so overwhelmed and burnt out. There has now been a human rights complaint filed against the Quebec Ministry of Health. There was a pretty deliberate sacrificing of the elderly, dependent population to protect our hospitals for the younger and healthier.
So, what lesson can we learn from the care home tragedies that can help us do better next time around?
There was a kind of top-down message about what we should do. Eventually instructions were defied or ignored, and that was good. My care home colleagues started sending patients to the hospital, and the hospital CEO said ‘we will take everyone’. The policy shifted from the ground up. But it didn’t happen fast enough. We remained in a remarkable situation where we had to triage, who in the care homes would get IVs - because we could only do so many at a time. The hospital ICU was not overwhelmed, but tragically, triage still happened by keeping old people out of hospitals, and many died.
The lesson is that a highly centralized Ministry of Health, even in a strong public health system like Canada’s, doesn’t always understand what is going on in the field. The networks ended up adapting their responses based on the evolving situation on the ground. My hospital eventually put together SWAT teams and we would send out teams to the care homes. Some of them were really abandoned. There was a scandal where people were found lying in their feces, not having been fed or cared for days.
What about treating the “whole person” you stressed this is part of your training – but how do you do this while battling a highly contagious infection?
The hardest experience that I have had as a physician was Covid. People were dying alone.
I had to talk to families who were distraught and angry. It was wrenching. What we have learned is that we really have to pay more attention to the whole patient. Patients were eating, but they weren’t walking around. So, they needed more physical therapy upon recovery. We really shot ourselves in the foot.
One of the things I learned from Ebola is that concerns over infection prevention and control can also impair our ability to deliver holistic and humane care.
Hopefully with the second wave [of Covid], we will be much, much more proactive about letting people in to see patients, getting people out and around the ward. In my hospital, they eventually set up a Covid ward for the elderly, where people could walk around.
Looking towards the fall and autumn, what do you expect? From the clinician’s perspective, is the virus becoming any less deadly, as some doctors now claim?
There is a tendency for viruses to become much less virulent over time. Although it is not clear, in the case of Covid, if there is less illness, less death among the elderly, right now. The other grounds for optimism is the behavioural changes that we have seen. Small behavioural changes, if taken up by enough of the population most of the time, can have a huge effect.
But pandemics teach you humility. In the winter, if it’s a bad flu year, then we can already be close to the limits of hospital capacity just with flu cases. And, fortunately or unfortunately, we have this ongoing experiment called the United States - which is showing us what to do - or what not to do.
What lessons do you bring from Canada back to Geneva about coping with this pandemic?
The policymaking needs to be very close to the ground. You need to do things differently, depending on where your epidemic is, as epidemics move quickly.
In Switzerland, there were concerns that there was quite a bit of muddle at the federal level, and squabbles between federal and cantonal level. So initially, the measures put into place were not the most draconian. But that didn’t matter because local responses appear to have been sufficiently robust. Switzerland is a small decentralized country, which makes it exquisitely responsive at the local level. The entire Canton of Geneva is only 400,000 people. That is the size of one neighbourhood in Montreal. In Québec decisions were made 300 km away in the provincial capital.
The second asset here is what you might call Swiss discipline. I don’t see it as a cultural trait as much as it is a reflection of the history of trust in public authority. Trust isn’t moral authority, it is earned. Strong democracies lead to populations that can enact necessary discipline because they have trust in their institutions.
As you have recently taken over as co-director of the GHC – how would you like to shape or strengthen the Global Health Centre’s role in public health education and research?
My Global Health Centre co-director, Suerie Moon and I feel increasingly the urgency of opening global health to new voices and perspectives. I had not realized until really the last six months, how bizarrely parochial and even “white supremacist” the global health arena can be. The way in which the playing field and the rules are set up to make the default choice the white person. I have seen this up close and personal, how people who are not from a certain pedigree are not valued. And if we don’t change this very soon, we will have more major, major trust problems, as we go forward to battle the pandemic and other critical diseases. Ebola in DRC was a wake-up call where communities protested the corruption and the disconnect between global health policy leaders, foreign aid workers and reality on the ground. If it keeps going on this way, we won’t have a “herd immunity” level of trust that allows us to have any kind of traction for global health programmes.
What can the Global Health Centre do about this?
It boils down to very practical things. When we organize events, to ensure that a diversity of views is included. We need to think about the way we frame issues, and the kind of knowledge that is valued in academia. That knowledge is often a male white, universalist perspective; there is a privileging of numbers. But how do we bring in an approach that is more particularistic? As we are not in a school of public health or faculty of medicine, we are in a good position to do this.
We are a school that stresses the social sciences and humanities. Global health is about power, it is about governance. It’s understanding power and politics that make you more effective.
Bottom-line lessons for global health?
I can have a vaccine, but I need to gain the trust of people and to mobilize resources in order to have the vaccine work in the world. We have to be able to work synergistically in the messy world of politics and with the biomedical world. The political, affective and emotional dimensions of public health policies need to be looked at quite seriously
In a sense, Covid has made things very, very easy for us. The health literacy of the world’s population has expanded enormously. Many more people understand issues in basic epidemiology, such as herd immunity. And most of all, in terms of issues ranging from access to PPE and vaccines to access to treatment among different populations, people are really seeing concretely, the links between politics and medicine.