Lucio Barreto, BSN, RN

It has been two years…

As the nation went into lockdown, we were activated to respond in overdrive to the needs of our communities. We were as blind about what the future held as the rest of the country, but we knew it was our time to carry the burden and make sure that our patients received the care they deserved. The most transformative power of this pandemic was not what we have learned, but rather how we learned.

We faced more than a virus…

During the last two years, we dealt with racial inequality. We understood that we did not have an America for all.  We saw that the ideal of equal rights was not there yet. We faced racism against blacks, Asians, Latin Americans—all normalized under the lens of nationalism and political rhetoric.

We learned that disinformation in the media—falsely claiming that COVID-19 is “nothing to worry about”—can derange our society and work as an obstacle for the common good.

We learned that competent leadership must be brave and walk side by side with their team. That leadership must be transformative and undertake rapid and radical changes to manage any imminent threat.

The pandemic created an opportunity to re-evaluate our lives. We had the time to measure what is important. We had the chance to understand the importance of human connections. We faced our own terrors, hidden by the busy workday, and stood in the mirror to finally see ourselves. We saw how important mental health is in our lives and the lives of others. We took the first step to destigmatize seeking help with mental health (though we are still far from the dreamed ideal).

We learned how adaptable we are. We saw the best and the worst in each other. We came to work filled with anxiety, fatigue, stress and burnout. We knew we were needed. We knew that our patients counted on us.

We cried with strangers at the bedside. We shared our own burden of family members and friends dying when we could not be there. However, we knew that wherever they were being cared for, someone like us was by their side, holding their hand.

We were happy and celebrated every time a patient was able to walk out of the hospital. We were angry when there was nothing else to do to save a life. We were frustrated when a coworker was sick. We were afraid to be the next patient on the stretcher.

We were flexible. We took good care of each other.  We dried each other’s tears.

We were resilient. They called us “heroes”. Heroes in scrubs.

What lies ahead: HOPE…

Hope that we do not repeat the same mistakes. Hope that we learned the lesson. Hope that tomorrow will be better.

We learned that we are strong together. We learned that we find a way.

Lucio Barreto, BSN, RN, CCRN, NE-BC, MICN, Clinical Program Manager, Emergency Medicine Quality and Safety, The Mount Sinai Hospital

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Challenges Ahead: A research review from Miriam Merad, MD, PhD

A  review of the immunology of COVID-19 was published in March 2022 in Science by Miriam Merad, MD, PhD, Mount Sinai Professor in Cancer Immunology and Director of the Precision Immunology Institute at the Icahn School of Medicine at Mount Sinai, and an international team of scientists. Here are excerpts:

Variants of Concern

As the virus evolves and new variants emerge, there have been concerns that such variants could increase pathogenesis by escaping from immunity generated through previous infection or vaccination or by inducing more severe disease. Some variants of concern, such as 1.351 (Beta), P.1 (Gamma), and the recently described B.1.1.529 (Omicron), have mutations that render them less susceptible to vaccine-mediated and infection-acquired immunity. It is less apparent whether some variants induce more severe disease upon primary infection than others, though strains such as B.1.1.7 (Alpha) and B.1.617.2 (Delta) are known to spread more efficiently, making it difficult to distinguish increased infection rates from increased severity.  As new variants emerge, it will be important to direct continued research efforts into identifying how such variants escape from either innate or adaptive immune responses.

Immunology of Long COVID

It is now clear that COVID-19 can lead to long-term disease—often referred to as Long COVID syndrome or post-acute sequelae of SARS-CoV-2infection (PASC)—in a significant proportion of survivors. Although there is no universal consensus in the definition of PASC, the Centers for Disease Control and Prevention defines it as a wide range of new, returning, or ongoing health problems that people experience four or more weeks after first being infected with SARS-CoV-2. By contrast, the World Health Organization defines it as a condition that occurs in people with confirmed or probable SARS-CoV-2infection, usually three months from the onset of COVID-19 with symptoms and that last for at least two months and cannot be explained by an alternative diagnosis.

A systematic review of 57 peer-reviewed studies with 250,351 survivors of COVID-19 who met their inclusion criteria for PASC showed that the median age of patients was 54.4 years, 56 percent were male, and 79 percent were hospitalized during acute COVID-19. At six months, 54 percent of survivors suffered at least one PASC symptom. However, non-hospitalized COVID-19 survivors who developed PASC were primarily middle-aged women.

In a survey of 445 non-hospitalized Danish COVID-19 patients, persistent symptoms—most commonly fatigue and difficulty with memory and concentration—were reported by 36 percent of symptomatic participants with a follow-up of more than four weeks. Risk factors for persistent symptoms included female sex (44 percent for women and 24 percent for men) and body mass index. The immunobiology of PASC is currently under investigation. Leading hypotheses include:

• persistent virus or viral antigens and RNA in tissues that drive chronic inflammation;
• the triggering of autoimmunity after acute viral infection;
• a disruption of the gut microbiota, potentially driven by virus persistence in the intestine;
• and unrepaired tissue damage.

 Concluding remarks and future directions

The COVID-19 pandemic has wrought massive disruption and resulted in the loss of countless lives; however, there have been silver linings. The particularly rapid development of highly efficacious vaccines is foremost among these and has established a playbook for the response to future pandemics.

One comforting prospect is the degree to which advances in our understanding and treatment of COVID-19 have been aided by an unprecedented degree of scientific cooperation. Free sharing of data has allowed us to rapidly glean critical insights into the role of the immune system in contributing to both protection and pathogenesis in COVID-19. Such insights will undoubtedly help us prepare for the next pandemic, just as decades of previous immunological research led to our current COVID-19 vaccines. However, many challenges remain, and our progress in ending this pandemic is threatened by inequitable distribution of vaccines and the rise of variants that are less susceptible to vaccination and prior-infection-mediated immunity.

As infections continue to occur, there remains a need for new therapeutics and hence a need for a better understanding of the pathophysiology of COVID-19. In addition to treating acute infections, there is a dire need to better understand and develop treatments for individuals with Long COVID. Another threat is the amount of misinformation and erroneous theories about the pandemic, vaccines, and therapeutic efforts that have been circulating in social media, some unfortunately introduced by scientists.

More than ever, interdisciplinary and integrative approaches to scientific collaboration and fighting misinformation are necessary to tackle these and other challenges that lie ahead.

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Lives Reshaped: A leadership story from Arthur Gianelli
We Were Resilient: A response from the front lines by Lucio Barreto, BSN, RN

Just over two years ago, the World Health Organization declared COVID-19 to be a pandemic. New York City quickly became the epicenter, and the Mount Sinai community rose to the challenge.

Now, at this moment of cautious hope, a cross-section of the Mount Sinai community—front-line providers, researchers, and leadership—took a moment to consider two questions about the pandemic: What have we learned, and what lies ahead?

Here are thoughts from some of those in research at Mount Sinai.

Judith A. Aberg, MD

There are many lessons learned in regards to pandemic response and therapeutic interventions. In an unfathomably short amount of time, we now have effective therapeutics and vaccines to prevent much of the serious illness and death associated with SARS-CoV-2.

We have learned that vaccines not only save lives but reduce the risk of developing Long COVID. Yet, we have also succumbed to political pressures and social media misinformation that have resulted in health disparities, especially among people in rural communities and in disenfranchised populations where scientific discovery, therapeutics, and vaccines are significantly less accessible.

We must do all we can to assure that the world is aware of the true threats of COVID-19 and to provide the education and resources to protect ourselves from emerging variants. Every time the pandemic starts to seem as if it might be over, people start letting their guard down to return to pre-pandemic activities—only to find themselves caught in another surge.

We are now approaching 500 million cases worldwide, including more than 60 million deaths, since the pandemic began. The United States has led in absolute numbers with almost 82 million cases and more than 1 million deaths. We must remain vigilant and assure access to resources, therapeutics, and vaccines for all.

Judith A. Aberg, MD, Chief of Infectious Diseases, Mount Sinai Health System
Dean of System Operations for Clinical Sciences, Icahn School of Medicine at Mount Sinai

“Challenges ahead”
Read an excerpt from a Science review of the immunology of COVID-19 by Miriam Merad, MD, PhD, and an international team 

The Simon Lab

What have we learned over the past two years: The COVID-19 pandemic has highlighted that in a crisis of such dimension, when time is at a premium, one needs to have infrastructures in place to deal with it. Most important is the forging of strong working relations. We created working relations between our research scientists and the clinical medical community that did not exist before. This allowed us to quickly develop and implement tests to measure SARS-CoV-2 antibodies, follow the evolution of the virus, and provide guidance on new treatment options.

I also learned of the remarkable dedication of the Mount Sinai community. Staff, researchers, students, doctors, and nurses worked endless hours at great personal risk to deal with the many challenges we faced. I am so proud of my lab members and volunteers who joined us every day over the past two years to advance our knowledge.  None of the progress we made would have been possible without the strong, competent, and supportive leadership of the school and the hospital.

What lies ahead: Thanks to the availability of COVID-19 vaccines, antiviral treatments, and prophylaxis options, we are in a much better place now. We will build on what we learned to ensure that we are better prepared for the future. For example, the Center for Vaccine Research and Pandemic Preparedness, which is co-directed by Florian Krammer, PhD, and myself, will help to provide the infrastructures and strong working relationships needed for dealing with SARS-CoV-2 variants and future pandemics.

Viviana Simon, MD, PhD, Professor, Department of Microbiology 

“The path forward”
Read what three leading microbiologists at Mount Sinai think about future of SARS-CoV-2 and its place in our lives 

Michael Schotsaert, PhD

The self-sacrifice of health care personnel and scientists during the COVID-19 pandemic—trying to understand this new virus and disease to come up with proper treatments—was enormous. Thanks to previous studies on corona- and other viruses and the availability of specialized high-containment laboratories like the ones at Mount Sinai, it was possible to unravel fundamental characteristics of the virus at record speed, which informed antiviral treatments and vaccine development.

Real-time sharing of research and clinical data was crucial and was facilitated by social media and existing and new collaborations between research groups and medical teams all over the world. Public health agencies like the National Institutes of Health and the World Health Organization played a major role in facilitating collaborations, not only between academic partners but also between academia and industry. The latter was crucial for developing, validating, and bringing to the clinic the novel, live-saving antiviral drugs, antibodies, and vaccines that are the key to a pandemic exit.

None of this would have been possible without the many years of investment in pandemic preparedness. The high death toll and burden on society caused by the COVID-19 pandemic, however, shows that even more investment is needed if we want to be ready to tackle the next time a pathogen with pandemic potential emerges. Therefore it is important to further invest in global pathogen surveillance and fundamental research, and to strengthen partnerships between academia, industry, and public health agencies.

Michael Schotsaert, PhD, Assistant Professor, Microbiology

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Lives Reshaped: A leadership story from Arthur Gianelli
We Were Resilient: A response from the front lines by Lucio Barreto, BSN, RN
Challenges Ahead: A research review from Miriam Merad, MD, PhD

Just over two years ago, the World Health Organization declared COVID-19 to be a pandemic. New York City quickly became the epicenter, and the Mount Sinai community rose to the challenge.

Now, at this moment of cautious hope, a cross-section of the Mount Sinai community—front-line providers, researchers, and leadership—took a moment to consider two questions about the pandemic: What have we learned, and what lies ahead?

Here are thoughts from some of those on the front lines at Mount Sinai.

Bernard Camins, MD, MSc

It has been more than two years since COVID-19 was declared a pandemic. Since then we have gained a tremendous amount of knowledge about a respiratory virus to which no one was previously immune.

We have learned that as a society, we must adapt and change our behaviors as more information becomes available. Science, after all, is the pursuit and application of knowledge based on available evidence.

For example, we learned that face coverings did prevent the transmission of SARS-CoV-2. Adherence to mask wearing not only prevented one from becoming infected but was considered an act of kindness by preventing others from being exposed in case a person was infected. We have also learned that even though an effective vaccine became available, viruses can develop mutations spontaneously that would render available vaccines less effective.

As another variant is moving through the country, we must always be vigilant that other variants may be forthcoming. We must never be complacent. We may have to start wearing masks in public spaces again if a new variant comes along that is more virulent than the Omicron variants. We may have to take another dose of the vaccine to keep up with the mutations. But then there is also hope that the worst may be behind us. One thing is certain, the world as we know it, will never be the same again.

Bernard Camins, MD, MSc, Medical Director, Infection Prevention, Mount Sinai Health System

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David Putrino, MD

Although acute COVID-19 numbers have slowed down for the time being, we are still in the midst of a mass-disabling event because of the sheer number of people experiencing Long COVID symptoms.

Throughout the pandemic, Mount Sinai has been at the center of research, advocacy and care for people with Long COVID. Over the coming months and years, it is critical that we strive for the same levels of clinical and research excellence that we have achieved during the first two years of the pandemic.

Investigating novel therapies, exploring mechanisms of underlying pathology, engaging in local and federal advocacy, and maintaining a high standard of interdisciplinary care will all be crucial to ensuring that people with extremely debilitating Long COVID symptoms have the best chance of a full recovery over time.

There are millions of people across the country depending on us to keep fighting, and we will honor that commitment.

David Putrino, PhD, Director of Rehabilitation Innovation

“We were resilient”
Read a personal story from Lucio Barreto, BSN, RN, Clinical Program Manager 

Tracy Breen, MD

What we have learned: it is impossible to overcommunicate.

Over the course of the surge, we were bombarded by an immense amount of new scientific information, clinical guidelines, regulatory requirements, supply chain challenges, and massive life disruptions.  The speed at which all these factors changed on a daily, and even hourly basis, meant that we were continually operating in a dynamic and disrupted environment.  One of the major takeaways for me was that is it simply impossible to overcommunicate with your teams.  And for leaders, true communication involves not only pushing out information and updates but listening to the people who are doing the actual work and incorporating that expertise into your strategy and planning.

Our best moments involved harnessing our front-line teams’ insight and creativity and then rapidly getting them the necessary tools and support to innovate.  In an acute crisis, this kind of dynamic exchange is easier to prioritize as other routine demands on leadership’s time and attention get put on hold. The opportunity for leaders going forward is how we incorporate and sustain that critical connection into our daily work; this is essential for us to succeed in the challenging times ahead.

Tracy Breen, MD, Chief Medical Officer, Mount Sinai West

Brendan G. Carr, MD, MS

We’ve been reminded how connected we all are. The lines are forever blurred between our professional roles and our roles as neighbors and family.

We’re all patients, we’re all caregivers, and our actions all impact each other.

It’s an enormous responsibility and an even bigger privilege to live and work alongside regular people quietly doing extraordinary things.

Brendan G. Carr, MD, MS, Professor and Chair, Department of Emergency Medicine

Heather Isola, MPAS, PA-C

The COVID-19 response allowed us to discover that compassionate care is the best of us coming together. When the time came to respond to the city’s and state’s call for help, the Mount Sinai Health System was there.  The Physician Assistants (PAs) were the first providers to shift into areas of medicine that were not their own, to care for teams that became sick, and to address the surge of patients entering the hospitals.  We learned that our skills, accumulated over time, are transferable and vital to help bring excellence to patient care.

Now, after the response, we know that PAs are integral to our health care ecosystem. It takes a village and optimal team alignment to answer to something bigger than us.  Our PAs answered the call, and in doing so, elevated our care in the process. The PAs, along with our physicians, other providers, nurses, and staff have persevered through the unimaginable and have come out the other side as better health care workers and resilient citizens of the Mount Sinai Health System. We have learned, and will continue to learn, that continued teamwork and compassion for our colleagues, families, friends, and patients makes a difference to the health and safety of our community.

Heather Isola, MPAS, PA-C, Vice President PA Services, Mount Sinai Health System

Kristin Oliver, MD, MHS

The tide began to turn on the pandemic with the advent of COVID-19 vaccines, but vaccines work in arms, not in vials. With only 13 percent of people in low-income countries vaccinated, we must focus on global vaccine equity.

In the world of vaccine delivery, the phrase “the last mile” describes the immense effort and ingenuity required to deliver vaccines to people living in the most remote areas of the world. Google it, and you find images of vaccines carried on the backs of donkeys along rocky paths, on small motor boats across jungle rivers, and by foot through otherwise impassable terrain. These logistic challenges are surmountable, but first we must prioritize and appropriately fund global health care infrastructure and support policies to share vaccine technology and expertise with global manufacturers.

There is another “last mile,” one equally present in the United States. It is the mile that seems to separate the doctor recommending the vaccine from the patient who is afraid of side effects, the public health ad campaign from its target audience. This mile will be harder to cross, and the effort will require more than funding. It can only be bridged by trust. I don’t yet have the answers to how we will do this, but I plan to start by listening.

Kristin Oliver, MD, MHS, Associate Professor of Environmental Medicine & Public Health, Pediatrics, Global Health

The COVID-19 pandemic has left a mark on the psychosocial landscape of the Mount Sinai Health System. Our workforce has been devoted to delivering world-class, skillful patient care during unprecedented times, but we also know that this work has come at a cost. Nearly 40 percent of the front-line health care workers that we surveyed in April 2020 experienced symptoms of anxiety, depression, and/or post-traumatic stress disorder; 20 percent continued experiencing these symptoms seven months after; and nearly 30 percent reported experiencing persistent burnout.

Despite these challenges, we have learned that distress and resilience co-exist. In this same survey group, many front-line health care workers reported a greater appreciation of life and emotional growth after pandemic-related trauma. The uptick in mental health resource utilization also speaks to the resilience of staff at Mount Sinai, but we have learned that systems-level support is critical to maintaining a culture of well-being. Our team’s research has demonstrated that health care workers who received strong emotional and leadership support tend to suffer fewer long-term effects of work-related stress. As we emerge from crisis, it is hard to predict what lies ahead, but it is clear that our Mount Sinai community is poised to grow from these challenges to meet future demands.

We in the Office of Well-Being and Resilience look forward to participating and contributing to this psychosocial recovery and growth by supporting well-being, resilience, and mental health initiatives across the system.

The Office of Well-Being and Resilience

What lies ahead: We see a need to continue to support the emotional well-being of our colleagues, teammates, and students through robust multi-tiered and collaborative efforts. Expansion of outreach, resilience-building workshops, leadership engagement, and behavioral health care is essential.

The Mount Sinai Center for Stress, Resilience and Personal Growth

Read more insights from Leadership
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Lives Reshaped: A leadership story from Arthur Gianelli
We Were Resilient: A response from the front lines by Lucio Barreto, BSN, RN
Challenges Ahead: A research review from Miriam Merad, MD, PhD