Robert Citronberg, M.D. is the director of the Division of Infectious Disease at Advocate Lutheran General Hospital in the Chicago suburb of Park Ridge, Illinois. He has been an infectious disease specialist for 28 years.
Harvard Political Review: Can you speak on the work you do at Advocate Health Care, and how has it changed during this pandemic?
Robert Citronberg: I’m an infectious disease physician. I’m currently the director of infectious diseases at Advocate Lutheran General Hospital. Before this pandemic, [my work was] just [about treating and preventing the spread of] general infectious diseases. … Since the pandemic began, it has been COVID-19 basically 24/7. That’s pretty much the only topic right now. We’re trying to keep an eye on other things as well that may pop up, but the primary focus has just been on COVID-19.
HPR: Have you recently learned anything new about COVID-19?
RC: At the beginning, we knew absolutely nothing, [so] we learned things every day: so much about drugs, what [the virus] does to the body, [and] how it’s transmitted. But I was thinking … the other day about what percentage of the disease we do know about [versus the percentage that] we need to know about, and I would say it’s probably not even 10%. Even as much as we’ve learned in the last three months, we actually still know very little about [COVID-19]. We don’t know how to adequately treat it. We don’t know if we can make a vaccine for it. We don’t understand exactly what it does to the body. There’s still so much that we don’t know about it.
HPR: Since there’s no vaccine or specific target treatment for COVID-19, what are medical professionals using to treat people?
RC: Really, what we’re doing is called supportive care. That means we are just supporting people to give their body a chance to get better. So it’s mostly giving them oxygen because sick people have very poor oxygen in their blood. Sometimes, if patients get put on a ventilator and can’t breathe on their own, it’s giving them blood products or things that will support them until they can get better. Now at the same time … there’s a bunch of drugs we’re trying out to see if they’re going to be of benefit, but at this moment, there’s no approved drug therapy. The crux of our treatment is really just supportive care.
HPR: Has increased access to testing affected treatment?
RC: It hasn’t affected treatment that much. What it has affected is being able to isolate people. When this began some months ago, we almost had no testing; we had no ability to test people in this country. We got to a really, really slow start. Now we can test many thousands [of] people a day. And what the testing does is it identifies people who have the disease so we can isolate them, and then we can trace their contacts. This is a very, very contagious virus. The way you get on top of it is to identify the people who have it, locate all of their contacts, and keep them isolated to prevent them from transmitting it to anybody else. That’s exactly what we do. So the testing really doesn’t play much [of a] role in treatment, but it certainly plays a role in isolating people to prevent them from transmitting [the virus] to others.
HPR: Could we have slowed the spread of COVID-19 several months ago?
RC: You know, we always look [back] in hindsight and say, “Could we have done anything differently?” Yeah, I think it’s one of those things where if you knew then what you know now, I think so. I think the one thing that we didn’t appreciate was how well this virus can be transmitted by people without symptoms. Our initial focus was all on people who had symptoms, whether those were cough or fever or other symptoms, and we were screening people for those symptoms of fever and cough. But we learned fairly quickly that this disease is spread very easily by people without symptoms. I think where the increased testing might have helped a little bit better is that if we had tested people without symptoms earlier on, we might have made a bigger impact [on transmission]. But we were basing our response off experiences from the other viruses — particularly the other coronaviruses, the ones that caused SARS back in the early 2000s. And the [SARS] virus is transmitted mostly by people with symptoms. So I think that … if we knew then what we know now about [COVID-19], we’d go after more people who don’t have symptoms with more mass testing. I think that was really the major opportunity we missed. We missed it in retrospect, but I’m not sure that we could have understood it at the time.
HPR: Is it too early for some states to begin reopening their economies? Should we be concerned that this will cause a possible surge in new infections and deaths?
RC: Yeah, that’s the main concern. You have to ask yourself what’s changed between now and two or three months ago, when we started all this social distancing. What’s changed is that maybe up to about 15% of the population has been exposed to this virus. And that’s not nearly enough to confer what we call herd immunity, which is when a large percentage of the population gets infected and prevents the virus from spreading. So that hasn’t [happened]. There’s not nearly enough people that have been exposed yet to make an impact on that.
I guess the advantage is that we now are much better at social distancing. I think when we reemerge and reopen the economy, it’s not going to be business as usual. The new normal is going to be social distancing and masks. So when you go to restaurants or stores, people are going to be spread apart. There’s going to be limited capacity at places. I think when we put those measures in place, you can really help to prevent or minimize that so-called second wave [of infections]. But if you just stopped everything today — no more social distancing, no more sheltering in place, everybody going out to restaurants, bars, etc. — you will see an enormous spike in new cases that might even be bigger than the first wave. That’s the real concern. You have to [reopen] understanding that there is risk and using techniques to mitigate the risk, and right now, the primary [solution] is social distancing and also mask-wearing in public.
HPR: What do you think about Governor Pritzker’s five phase plan to reopen the economy in Illinois?
RC: I think it’s smart. You have to have a stepwise approach. Also, what I liked about his plan is it doesn’t have specific dates attached to it. There are other plans and other states that say, “Okay, May 1, we’re doing this. June 1, or July 1, we’re doing this.” You can’t really set an arbitrary date [to reopen]. The decision has to be based on what is happening to the disease in your community. And that also changes a lot [with] geographic variation. So in Chicago, we happen to be particularly hard hit. Other parts of the country are not hard hit at all, so they might be able to reopen sooner. I think [Pritzker’s] plan is good, and basically, it’s logical. It starts with smaller groups. The last thing to occur will be large gatherings like sporting events and concerts with fans. That’s not going to be for a while. That’s not going to be until we really are sure that we have a handle on this pandemic. So I think the stepwise approach is good. Even though the right thing to do from a medical standpoint is still to stay apart, we understand that the economy is really suffering and really hurting. We have to make every effort to reopen the economy with the least risk. It’s not going to ever be without risk, but we just need to use the strategies that are going to mitigate the risk.
HPR: You’ve done a couple of Q&A’s on Facebook and Instagram, answering people’s questions about the coronavirus. Have you found social media to be an effective tool in this time for spreading information to the public?
RC: If [information] is from reputable sources, yeah, for sure. The problem is that, you know, there is so much misinformation that is out on social media that it blurs the facts. There’s no problem with getting information from social media as long as it’s from reputable sources. And I tell people to make sure that whatever they’re reading is referenced and cited so that they can fact check, to make sure it’s not just someone’s opinion who may not really be in the mainstream. So I think it’s a two-edged sword. I found [social media] to be a useful tool to help educate, [and] that’s really my main interest — to help educate people. But there is also so much misinformation. It’s kind of maddening that information is propagated when it is just simply untrue. So you really have to filter out disreputable sources and just stick with very reliable news sources.
HPR: Due to the quarantine, some medical care has been moving online through virtual appointments. Do you think this trend of digital healthcare will continue beyond this pandemic?
RC: Oh, without a doubt. I think there’s going to be a lot of things that happen as a result of this pandemic that will be permanent changes. A lot of them will be good, and I think telehealth is one of them. It’s probably long overdue. A lot of medical care can be provided remotely via telemedicine. Now, some things are always going to require the patient to be in person. But a lot of what we do can be accomplished remotely. So I think that [telehealth]’s for sure going to be one of the things that continues after the pandemic. … Some people estimate that maybe up to 80% of office visits will be done via telehealth in the future. That’s pretty astounding considering where we started off.
HPR: What do you think life will look like in six months, a year, and beyond that?
RC: You know, it really depends. It’s so variable. Right now, I would just work backward. Most people think this whole pandemic is going to last about two years in total. It might be a little bit shorter if there’s a vaccine that becomes available and works. I would say two years from now, [the pandemic] should be over. If it’s not, we’re going to have a big problem. A year from now, we should probably have made good strides. Hopefully, we’ll have a vaccine by then. Six months from now — let’s put this trajectory towards the end of 2020 — I think it’s a mixed picture. It’s probably going to vary a lot regionally. We’ll have some regions that are back to normal and others that are still having a lot of cases. There’ll be a lot of geographic variation and regional variation. But I think by the end of 2020, we should start to see a real return to normalcy — being able to go out and do things still with some restrictions. I think it’s going to look a lot more normal by the end of 2020 than it looks right now.
Image Source: Robert Citronberg