Published: April  2022

Since 2004, Eric Toner, MD ‘78, has focused his career on healthcare preparedness for everything from catastrophic events to pandemics to bioterrorism. Today he is a senior scholar with the Johns Hopkins Center for Health Security and a senior scientist in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. He has authored numerous papers and government reports on topics related to disaster planning. We spoke to him in January 2022 for Virginia Medicine.

What initially brought you to UVA?

I grew up in Fairfax County, Va. I was a pre-med student at UVA, and then when it was time to apply to medical school, UVA was my first choice. I had worked all through college – at the hospital including the coronary care unit, first as a Madison House volunteer and then in several paid positions. I knew the hospital, I knew the people and I really wanted to stay at UVA, stay in Charlottesville and at the school. I was lucky enough to be accepted.

You’ve worked in healthcare preparedness since 2004, but prior to that you were a practicing physician. Can you tell us about your career path?

After medical school, my intent was to be a cardiologist. I went to MCV for residency and after doing rotations through the cardiology division there, I was sure I didn’t want to be a cardiologist anymore. I had a public health service scholarship to work off, and my wife, Jacquie, had a training position as a clinical psychologist in Baltimore, so I put my career plans to the side a bit. We moved to Baltimore, and I took what I thought was going to be a one-year job in the Emergency Department at St. Joseph Medical Center in Towson, Md. As it turns out, that job turned into a career. I had never intended to go into emergency medicine, but that’s where I ended up.

How did you end up shifting to hospital preparedness?

In addition to my clinical practice, I had administrative responsibilities at the hospital, one of which was the hospital disaster committee. After 9/11, that became a much greater responsibility, and then after the SARS epidemic, it was even more time consuming. Eventually it became a half-time position, and by 2004, I decided something had to give because I couldn’t keep up the clinical and administrative work. I gave up my clinical practice and to focus on the disaster preparedness stuff full-time. I left the hospital where I had been practicing for 23 years and joined this group, which is now at Johns Hopkins.

As someone who has focused on hospital preparedness for so long, how do you view the challenges that hospitals have faced during the COVID-19 pandemic?

Well, the challenges have been many and very difficult. I think that most hospitals have worked hard to do the best they could under extraordinarily difficult circumstances. But no hospital was prepared for the kinds of stresses that they’ve experienced – the lack of PPE initially, what we thought was going to be a critical lack of ventilators, certainly a lack of therapeutics, and now a critical lack of staff. Hospitals have just been trying as hard as they can to do the best they can under extraordinary circumstances.

For at least 15 years prior to the pandemic, I’d been trying to make people aware that a pandemic of this magnitude could happen and that we need to prepare for disasters or pandemics that are much worse than things we’ve experienced in the past. I would say that most hospitals did not take it seriously, including my own. I think they take it more seriously now. I think the question will be how seriously they take it five years from now.

In the world of hospital preparedness, we go through these panic-neglect cycles where an event happens, and everybody’s hair gets set on fire. Then when it’s over, they go back to hibernating until the next event. Hopefully this will remain in the forefront of collective memory for a long time.

Why do you think they weren’t listening before? Was it a matter of budget or just not thinking that it could happen here?

Well, several things. First of all there is a tendency that many people have, not just hospital administrators, to deny that bad things will happen to them. People always think that terrible things happen to other people, not to them. So there’s that bias in thinking to begin with.

From the position of a CEO of a hospital, you’re faced with a limited budget. If you have a million dollars in the budget, is it better to spend a million dollars on preparedness for an event that may never happen or to build a new parking garage that’s needed to support a new oncology unit at the hospital? Well, I think if I were the CEO, I would vote for the parking garage. I would take that gamble. I think that’s what most people have done, and I admit that’s not irrational. I think it makes sense, but eventually you lose the gamble. That’s what happened. Even though I can’t tell you when the next crisis is going to happen, bad things happen, and we need to be better prepared than we were before.

You co-authored a paper in October 2021, and you were looking at the policy changes needed to save lives and prevent societal disruption. There was a focus on masks and respirators. Do you see mask wearing as a new way of life?

After the pandemic is over, I don’t want people to wear masks every day all the time, but I do think that we can learn from the experiences of some Asian countries where they do wear masks during flu season in public or particularly in crowded places. In places like Taiwan and Singapore, during flu season, if you get on a subway and you’re not wearing a mask, people think you’re horribly rude. I think there’s a lot of wisdom in that. I think that when you have a respiratory illness, you should wear a mask. During flu season, if you’re in a crowded public space, you should wear a mask. I would hope that these would become normal things. I don’t think it’s necessary for everybody to wear a mask all the time but I do think that there are times when it makes a lot of sense and is something that we should do much more of.

Another study you co-authored in December 2021 said the following: “The findings of the study demonstrate that the failure to bring primary care providers into a front line role as responders alongside public health resulted in many missed opportunities to provide better quality care, faster testing, more effective contract tracing, greater acceptance of vaccination, and better communication with patients.” Can you talk a little bit about that and the lessons learned there?

This was a project to look at the interaction between primary care providers and public health and during the pandemic. What we found through many interviews with practitioners is that there was very little interaction, for the most part, between primary care doctors and public health practitioners. They were each in their silo and they weren’t communicating, yet there’s a lot of potential for collaboration. Primary care doctors largely were left on their own. They didn’t get PPE. They weren’t asked to participate in testing early on or in contact tracing, and both could have been very helpful. They could have also been much more helpful for vaccinations than they were able to be.

There were exceptions, and the exceptions were primarily federally qualified health centers, which treat a very poor, largely immigrant population, and are at least partially funded through the federal government, which enables them to be able to work more closely with public health. The typical primary care doctor was not involved and was not getting a lot of information, so they were pretty much on their own. That was a big, missed opportunity in our view.

Are you hopeful that lessons have been learned during the COVID-19 pandemic and that things will change for the better as a result?

Yes, I am. I think for the current generation of doctors and nurses who have been on the front lines, this is a moment in their lives that they won’t forget. The experiences they’ve had will be with them forever, in some cases along with PTSD. The ways that they have had to adapt and the lessons they individually learned, I think, will be remembered and applied to their planning for future events.

I’m less certain about what governments will do, both state and federal governments. I think their memories are shorter, and I’m less certain that the federal funding and state commitments that are needed to support hospital preparedness will be there five years from now. A new administration down the road, if nothing bad happens, could decide it was no longer a priority for them. In 2001 and going into 2002, everyone was sure that disaster preparedness was going to be a top priority, but just a couple of years later, funding was cut in half.

Speaking of PTSD among healthcare workers, as a physician yourself, are there things that you think can be changed in order to alleviate that stress going forward?

We need to create more surge capacity in hospitals, meaning that we can’t run them as lean as we have, with just enough staff and just enough supplies, just enough of everything, so that we have some room to flex when bad things happen. It’s not uncommon to have a bad flu season that severely stresses hospitals for at least a matter of weeks. It’s not the same as what they’ve experienced during COVID-19, but it is clear that we have been cutting funding for hospital preparedness too closely.

Hospitals are businesses, and they can’t run a deficit year after year, so they have a financial imperative to run as lean as they can. I think that there needs to be more funding from the federal government and from states, and hospitals have to be willing to spend more of their money on preparedness by creating and maintaining surge capacity. If we do that, there will still be stress, terrible stress on hospitals during something like COVID-19, but it won’t be as bad, and they’ll be better able to weather more common kinds of events.

Anything else you would like to share?

One thing that has struck me is what a good education I got at UVA. Over the course of my career, I’ve interacted with many, many other physicians, and I really think that UVA prepared me well. I learned a lot and was well-equipped going forward. I’m very pleased with what the University gave me.