The four pillars of our strategy—hygiene, distancing, screening, and masks—will not return us to normal life, but, when signs indicate that the virus is under control, they could get people out of their homes and moving again. As I think about how my workplace’s regimen could be transferred to life outside the hospital, however, I have come to realize that there is a fifth element to success: culture. It’s one thing to know what we should be doing; it’s another to do it, rigorously and thoroughly.
My eighty-three-year-old mother lives in a senior-living community called Lasell Village, not far from my home. It has two hundred and fifty residents, nearly two hundred staff members, and three levels of care, from independent living to twenty-four-hour skilled nursing. Initially, the leadership implemented three of the four measures of the plan used at my hospital: hygiene, distancing, and screening. They put up hand-sanitizer dispensers and secured enough disinfectant to wipe down every door handle and high-touch surface multiple times per day. They banned family visitors (like me) and asked residents to stay in their apartments or in outdoor walking spaces. The dining room was closed, and meals were delivered to residents’ doors. Temperature and symptom checks were instituted at the entrance for all, which resulted in many personnel going into self-quarantine.
But it was not enough. An outbreak occurred in a housing unit for disabled residents. Four of the eight residents there became infected, possibly by a staff member who subsequently tested positive for COVID-19. All four died. The week that my health system mandated masks, Lasell Village began requiring its staff to wear them, too, although because of a shortage of surgical masks, most employees got only one per week, plus a backup cloth mask. A few days later, residents and local nonprofits had sewed enough cloth masks to distribute one to every resident, as well.
“I wake up every night worrying,” Anne Doyle, the president of Lasell Village, told me. “The tiniest little decisions have consequences”—such as how to triage the dwindling supply of hand sanitizer. But the worry that keeps Doyle up most nights isn’t logistics, she told me, though they are an unending struggle. It’s culture—how people live and work together every day.
In hospitals, we have had to learn how to bring the stringent antiseptic standards of the operating room into the professional culture of other parts of our institutions. This requires absorbing the detailed practices that keep us from transmitting germs in a given setting—like the rule at the operating table that, once you’re scrubbed in, you never let your hands fall below your waist. Even more, this requires developing norms about how to address lapses in rules, so you can comfortably call one another out when you see a standard slipping and still enjoy working together. This isn’t simple; I’ve seen surgical colleagues in the hallway pop their masks down below their noses to talk, which they never would have done across an operating table, yet I am hesitant to call out the lapse.
Culture is the fifth, and arguably the most difficult, pillar of a new combination therapy to stop the coronavirus. People tend to focus on two desires: safety and freedom; keep me safe and leave me alone. What Doyle says she needs her people—both staff and residents—to embrace is the desire to keep others safe, not just themselves. She needs them to say, “I’m worried about my sore throat, and I am going to stay home.” Or “I am O.K. with being reminded to pull my mask up.” That is the culture of the operating room. It’s about wanting, among other things, never to be the one to make someone else sick.
At Lasell Village, Doyle is doing what she can to create cultural change under pressure. She has made sure that all her staff has enough paid sick time. “Most people have a ton of sick days. For those who don’t, we make it clear that we’ll top up whatever they have in order for them to adhere to precautions around the coronavirus,” she said. She’s worked to foster an atmosphere in which everyone will take a runny nose seriously. Residents, however, often have outside aides. When it became clear to Doyle that these aides weren’t necessarily getting adequate support, she had her team track them down, and made sure they had masks and training. In March, feeling flu-like symptoms, Doyle set an example by putting herself into self-quarantine. Her symptoms worsened, and it was a full three weeks until she was able to be tested and to return to work.
Every day, there’s a new problem to solve, and she asks employees and residents alike to figure out how to rise to the challenge. “When you have a community that cares about each other, then people are interested in adhering [to the guidelines] for other people,” Doyle told me. All the effort appears to be making a difference. The frequency of cases among residents fell substantially after the initial outbreak. Lasell Village went from five cases per week down to two and then one.
The combination therapy isn’t easy. It requires an attention to detail that simply staying in lockdown does not. But, during the crisis, people everywhere have shown an astonishing capacity to learn from others’ successes and failures and to rapidly change in response. There is still much more to learn, such as whether we can safely work at less than six feet apart if everyone has masks on (the way nurses and patients do with one another) and for how long. But answers will come only through commitment to abiding by new norms and measuring results, not through wishful thinking.
As political leaders push to reopen businesses and schools, they are beginning to talk about the tools that have kept health-care workers safe. The science says that these tools can work. But it’s worrying how little officials are discussing what it takes to deliver them as a whole package and monitor their effectiveness. On April 24th, as the first states began relaxing restrictions, the Times ran a picture of a barber in a suburb of Tulsa, Oklahoma, mask askew, nose poking out, clipping the hair of an unmasked customer. The week before, the county had experienced ninety-one new coronavirus cases and five deaths, an increase from the prior week. The government had no formal plan for surveillance testing to look for early signs of failure. Many leaders didn’t even seem interested. President Trump has sought to compel meatpacking plants to stay open, even though thousands of workers have been infected by COVID-19. He has encouraged protesters to flout public-health guidelines, and seems to consider it embarrassing to set the example of wearing a mask—even as the virus became the country’s top cause of weekly deaths in mid-April and then penetrated the White House. This is about as far as you can get from instilling the culture of the operating room.
Still, regardless of what model politicians set, more and more people are figuring out how to do what has worked in health care, embracing new norms just as we accepted social distancing. We see proof of a changing culture every time we step out and find a neighbor in a mask. Or when we spend time to make our own fit better. Or when we’re asked whether we have any concerning symptoms today. Or when we check to see whether the number of COVID-19 cases in our community has dropped low enough to warrant reëntry. If we stick to our combination of precautions—while remaining alert to their limitations—it will.