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In the final days of 2019, health authorities in Wuhan, China, found themselves treating dozens of patients for a new strain of pneumonia. On January 11, 2020, China’s state media reported the first death in Wuhan from the new disease. By January 21, SARS-CoV-2, the virus that causes COVID-19, had made its way to Japan, Korea, Thailand, and the United States. Two days later, with deaths in Wuhan reaching 17, Chinese authorities canceled planes, trains, buses, subways, and ferries in and out of the city. The world worried, and Cleveland worried with it. Rightfully so. On March 9, Ohio confirmed its first three cases of COVID-19, all in Cuyahoga County. Governor Mike DeWine declared a state of emergency. Ohio colleges sent students packing. Anxiety levels rose. Consumers panicked, emptying supermarket shelves of toilet paper and hand sanitizer. Everywhere people turned, there was talk of “flattening the curve,” referring to the mountain-like spike in cases expected in coming weeks. Sneezes and sniffles turned to fear, morale to gloom.
Two days later, on Wednesday, March 11, MetroHealth CEO Akram Boutros, MD, announced a free COVID hotline, open to anyone, 24 hours a day, seven days a week, and appointed Dr. David Margolius, the health system’s Director of Internal Medicine, to manage it. The plan was for MetroHealth doctors to calm fears, listen for symptoms, provide medical advice, and keep the disease from spreading. On March 13, the hotline opened and MetroHealth doctors and nurses, working around the clock, took calls from 37 patients. The next day, 81 people called. On March 17, that number jumped to 265. The calls came from Cleveland, of course, but from Dayton, Columbus, and Pittsburgh as well.
CHAPTER TWO
with a Missionary Zeal
Thousands of doctors and supervisors of City Hospital, now MetroHealth, have protected the health of the City and Cuyahoga County for nearly 200 years.”
“
the plague of the pox
IT WASN’T JUST THE HIGH FEVER, THE ACHES, OR THE DEBILITATING FATIGUE. It wasn’t simply the rash that developed in the mouth, spread to the throat, and extended down the arms and legs. It was the blistering red pustules that gave the disease its name—smallpox—and left many victims blind, badly scarred, or dead.
In August 1845, when news spread in Cleveland that a man with smallpox escaped from the local “pesthouse,” residents went into a rage. In a matter of hours, a mob marched to the pesthouse and destroyed it. Construction on a new pesthouse, next door to the Poorhouse of City Hospital on the grounds of the Erie Street Cemetery, began the next day. A mob marched again, this time to stop the construction, but a marshal and his posse turned them away. The furious crowd returned a third night. This time, they attacked the Poorhouse—not with weapons, with their shoulders, and with such force they tipped the building on its side. Still, city officials succeeded. They righted the Poorhouse, provided care for victims of the pox, and within weeks—using isolation, quarantines, and vaccinations—halted the spread of smallpox in Cleveland.1
Ten years later, when a more ravaging outbreak spread across Cleveland, it was the acting director of City Hospital, Dr. J.H. Marshall, who stopped it. Taking lessons from 1845, he made sure hundreds of the new city’s residents were vaccinated. With that, Dr. Marshall became one of thousands of doctors and supervisors of City Hospital, now MetroHealth, who have protected the health of the City and Cuyahoga County for nearly 200 years. Protecting public health and building hope was what Cleveland’s longest-serving hospital did from its founding in the 1830s with cholera. What it did with smallpox in the 1840s and again at the turn of the 20th century.
Cleveland’s smallpox cases exploded once again in the late 1800s, from 70 in 1898 to 1,232 in 1901. Deaths rose from zero to 20 and soared to 224 the following year. In 1901, newly installed Cleveland Mayor Tom Johnson, who would come to be called “the best mayor of the best-governed city in the United States,” pleaded for help from Dr. Martin Friedrich, the city’s chief health officer and a physician at City Hospital. The mayor was desperate for Dr. Friedrich’s help because smallpox was jeopardizing the survival of the City. Health officials in New York were threatening to keep that state’s residents away from Cleveland, and the mayors of Buffalo and Detroit were warning of blockades of goods shipped from the City. Dr. Friedrich not only helped isolate smallpox patients, he also launched the largest disinfection program in the City’s history. He sent crews with heavy sprayers filled with formaldehyde, a common disinfectant at the time, to douse the homes of the infected as well as the homes of their neighbors. By summer, the virus lay dormant, but Dr. Friedrich knew that by the first frost it would be back “with renewed violence.” In turn, he issued new orders for sanitary patrolmen to disinfect every house in Cleveland.
It worked. For a while. But when out of towners arrived in the winter of 1901 to 1902, they brought new cases of the pox with them. Again, City Hospital led the charge. Its staff isolated the travelers and worked with city officials to adopt new standards to track the disease, as well as public health as a whole, making Cleveland one of the first cities in the United States to do so.
When a more ravaging outbreak spread across Cleveland, it was the acting director of City Hospital, Dr. J.H. Marshall, who stopped it.
In May 1902, another traveler settled in a Cleveland lodging house. The man was sick with the often-fatal hemorrhagic smallpox, named for the extensive bleeding it caused in the abdomen and under the skin. A single case could quickly infect an entire neighborhood. Those sickened could die within days. The traveler spent four days infecting his fellow vagabonds at the lodging house. Cases surged, and fear gripped the City. Churches canceled services. Kentucky officials threatened to build a blockade along the Ohio River. Schools made the smallpox vaccine mandatory, the Chamber of Commerce urged businesses to do the same, and funeral processions throughout the city convinced the public to cooperate.
Once again, City Hospital played a central role. By August 1902, every case of smallpox was isolated at Detention Hospital. Opened a year earlier, Detention Hospital replaced the Poorhouse as the home of City Hospital. Dr. Friedrich’s team of 183 vaccinators, including many City Hospital doctors, inoculated Cleveland against this strain of the pox. That fall, more than 100,000 residents—25 percent of the City’s population—had been vaccinated.
Dr. Friedrich’s efforts paid off. In 1903, the smallpox death toll dropped by 90 percent. In 1905, no City resident died of the disease.
Dr. Friedrich and the doctors and nurses of City Hospital did their part to protect the health and wellness of the community—a tradition they would resurrect that same year, as one epidemic ended and another began.
Dr. Friedrich’s efforts paid off. In 1903, the smallpox death toll dropped by 90 percent. In 1905, no City resident died of the disease.
doctor, c. 1910.
tuberculosis
The White Plague, Black Cleveland, and Treatment Built on Trust
On August 23, 1905, Gustav Jacobs, 57, wandered amid the tombstones at Cleveland’s Riverside Cemetery, not far from City Hospital. “I just want to walk around here for a little while,” he told cemetery workers who offered him help. “I want to listen to the birds.”2
On their evening walk, two City Hospital doctors noticed a disturbing addition to the bridge in the cemetery. One end of a rope was tied to the railing. At its other end dangled the body of a man. The doctors hurried over, hauled the man up, and felt for his pulse. He was cold to the touch. In his jacket pocket, they found a handwritten note: “I am Gustav Jacobs.” It was a name one of the doctors recognized. He was a patient at the TB sanatorium at City Hospital and, following a relapse, had grown despondent.
That same year, close to 140,000 Americans lost their lives to TB.3 Its nicknames included “the White Plague” and “Consumption,” for the way it turned its victims pale and the way it consumed their bodies. In the early 20th century, medical treatment was limited to rest and fresh air. Some patients recovered. Many simply wasted away.
In Cleveland, though, thousands of lives were saved, in large part due to the work of Dr. John Lowman of City Hospital, the doctor who founded the Anti-Tuberculosis League of Cleveland, the ATLC, in 1905, the year Gustav Jacobs died. In 1907, the ATLC, which would later become the American Lung Association, set up tent after tent on the Scranton Road property of City Hospital, to treat patients with “the fresh air cure.” The tents also kept the disease from spreading from patient to patient inside the hospital. In 1913, Dr. Lowman expanded that work with the opening of Sunny Acres, the two-story TB sanatorium on 75 acres in Warrensville Township, chosen for its elevation and fresh breezes. Sunny Acres was managed by the City of Cleveland, and its staff worked closely with City Hospital on TB treatment and prevention.
From 1870 to 1920, TB deaths in Cleveland plunged by 50 percent. Dr. Lowman and the Anti-Tuberculosis League of Cleveland deserve much of the credit. But a serious problem remained: Black residents were dying of the disease far more often than White residents. In 1920, 340 of every 100,000 Black Clevelanders died of TB compared with 83 of every 100,000 White residents. Over the next ten years, the rate stayed the same for Black residents while it tumbled by 40 percent for Whites. Decades later, as City Hospital evolved into Cleveland Metropolitan General Hospital and then MetroHealth, doctors and nurses helped erase that difference, too. Much of the credit belongs to three of its physicians: Dr. Joseph Stocklen, Dr. Frits van der Kuyp, and Dr. Emmanuel Wolinsky.
Dr. Stocklen was the first Controller of Tuberculosis for Cuyahoga County and served as Superintendent of Sunny Acres Hospital. He was also the physician who established the city’s two outpatient TB clinics, one on the East Side and one on the West Side, and who began, like other tuberculosis specialists at the time, moving patients out of the sanatorium and back home. It was a move made possible with the discovery of effective medication that replaced fresh air as a cure. The clinics provided diagnosis and treatment along with community-wide TB screenings for food handlers, barbers, beauticians, teachers, and other workers who required it.
Dr. van der Kuyp joined the program in 1969 as Director of Medical Services and became the Controller of Tuberculosis for Cuyahoga County in 1974 as the trend toward outpatient treatment took hold. By the early 1980s, he oversaw a handful of doctors and a staff of public health nurses who cared for 800 patients at the Cuyahoga County TB Clinic—managed by MetroHealth—on Carnegie Avenue and East 46th Street.
From 1870 to 1920, TB deaths in Cleveland plunged 50 percent. Dr. Lowman and the Anti-Tuberculosis League of Cleveland deserve much of the credit. But a serious problem remained: Black residents were dying of the disease far more often than White residents.
Dr. van der Kuyp knew that many TB patients could beat the disease with a regimen of two different pills a day—often accompanied by an additional injection—and plenty of patience. The problem was that patients needed to take the medication for a year, sometimes two, and the drugs sometimes caused hearing loss, nausea, and other side effects. As a result, patients would stop taking the medication as soon as their symptoms let up, pass the disease on, and, in some cases, become hosts for hard-to-beat, drug-resistant strains of TB. To Dr. Van der Kuyp, there was an obvious, but not so simple, solution: administer every dose of medication under the watchful eye of a health worker. That led to another problem: public health nurses, largely responsible for home visits, did not have the time to watch everyone take their medication. On top of that, there was a trust issue as nearly all the nurses were White, while a large percentage of TB patients were Black.
Dr. van der Kuyp’s solution was to hire “TB counselors” trained to provide daily visits to patients’ homes, spend time with them, watch them take their pills, talk to them afterward—to ensure they swallowed the medicine—and, in the process, get to know them. To further build trust, he made sure Black patients received house calls from Black counselors.
With the full support of Dr. Stocklen, the Cleveland TB team was largely responsible for developing what came to be known as “Directly Observed Treatment” or D.O.T., which was so successful, other cities began adopting it as well.
As Dr. van der Kuyp said, “The counselors had an enormously positive influence on their patients’ well-being and their response to treatment. By having people who looked like them, you had better acceptance, improved compliance.” It was also a method Cleveland Metropolitan General Hospital, later MetroHealth, taught to medical residents at the area’s other hospitals who came to the clinic for TB training. Eventually, the US Centers for Disease Control and the World Health Organization adopted D.O.T. too, long after Dr. van der Kuyp introduced it in Cleveland.
All these years later, Dr. van der Kuyp, who retired from MetroHealth in 2016 after nearly 50 years, tells the story of one patient, Charles Pennington, to illustrate what a difference counselors made using D.O.T.
“Charles Pennington” would take his medicine for a while, then quit, so his TB would be reactivated, compromising his health and the health of others as he became more contagious. TB counselors would go to his address, but he was never home. When TB counselor Nebraska Newell first joined the clinic, staff members figured finding Charles Pennington would be a good test. Mr. Newell had a big heart, shoulders broad enough to fill a doorway, and a keen ability to think like a TB patient. Within a matter of hours, he returned to the clinic with the patient in tow.
“First of all, his name’s not Charles Pennington,” Mr. Newell reported. “Charles is his last name. Pennington is his first name. Whether you look for Charles Pennington or Pennington Charles, you will never find him. You have to ask for ‘Popcorn.’” After that, “Popcorn” completed his regimen and made a full recovery. This model of TB care proved so successful that, in March 1978, the county closed the TB Clinic on the city’s West Side and moved all the services to the East Side. It wasn’t just their outreach that made a difference. They owed much of their success to Dr. Emanuel Wolinsky.
A giant in the field of microbiology, Dr. Wolinsky came to City Hospital in 1956 as director of the bacteriology lab, one of many elite research clinicians hired by Dr. Charles H. Rammelkamp in that era. He arrived already having conducted much of his groundbreaking research into TB medication with his mentor, Dr. William Steenken.
Drs. Wolinsky and Steenken met while Dr. Wolinsky was treated for TB at the Trudeau Sanitorium at Saranac Lake, New York, soon after graduating from medical school. Working together, the two tested hundreds of combinations of antimicrobial drugs and related substances to identify regimens strong enough to kill TB-causing bacteria, gentle enough in terms of toxicity, and not prone to drug resistance. Their work allowed drug companies to develop dozens of treatments, abandon many others, and save thousands of lives around the world.
While Dr. van der Kuyp developed the strategy to fight the war against TB, Dr. Wolinsky gave them the weapons they needed to win. MetroHealth continues to win that battle today. Unlike smallpox, which was eradicated worldwide by 1980, TB continues to kill, taking close to 1.5 million lives every year. Not in Cleveland, though. In 2020, Chicago had three TB cases for every 100,000 residents. Akron, Columbus, Dayton, and Youngstown reported four cases for every 100,000 residents. In Cleveland, the case rate was 2.4—thanks in large part to MetroHealth, which, once again, would take lessons learned from one epidemic and apply them to the next.
While Dr. van der Kuyp developed the strategy to fight the war against TB, Dr. Wolinsky gave them the weapons they needed to win.
Twelve months later, 108 physicians had provided COVID care to 40,000 people through the hotline, some days talking to more than 400 patients. Doctors and nurses referred callers to testing sites and recommended when to isolate at home and when to go to a hospital. By keeping people from doctors’ offices, they stopped the spread of the disease. That helped preserve the dwindling supply of masks, gowns, and other personal protective equipment. Another beauty of the phone line was that it allowed everyone, not just those with high-speed computers and Internet service, to have a doctor’s visit from the comfort of home.
In those early days of the pandemic, COVID projections were daunting. Ohio expected nearly 10,000 cases a day in early April. Instead, the state hit its peak on April 20: 1,317 cases. The curve had been flattened—with a lot of help from MetroHealth staff and its commitment to protecting public health.
But other worries quickly emerged. What about people living in halfway houses or homeless shelters? What about residents of group homes for the developmentally disabled or elderly? Many of those homes lacked medical staff. Residents couldn’t be bused to emergency departments to be tested. And it was impossible, in many cases, to insist on masks, especially for those with disabilities such as autism, spina bifida, or Down syndrome.
“We need all of our residents tested!” a nurse manager at one home implored in a call to Dr. Margolius after a resident tested positive. The request might have gone unheeded at another hospital, but Dr. Brook Watts, MetroHealth’s Senior Vice President for Quality and Chief Medical Officer of Community Public Health, knew how quickly the virus could spread among group home residents. She also had a clear understanding of the stress that would place on people with disabilities and their families. She has personal experience with Down syndrome. So when Dr. Margolius told her about the call, Dr. Watts gathered up a group of nurses and dozens of test swabs and made a house call. MetroHealth staff swabbed all the group home’s residents. They swabbed all the staff members on that shift. And they swabbed all the staff members, waiting in their cars, to begin the next shift. For months afterward, MetroHealth tweaked what it learned from these “house calls,” applying the information it gathered to vaccinations and boosters. MetroHealth staff braved rain, hail, and snow. They worked in shelters, bars, and parking lots. They opened vaccination sites in a strip mall, in schools, and in the state’s largest homeless shelter in Cleveland.
By the end of 2021, MetroHealth’s COVID hotline had fielded more than 66,000 calls from across the United States and Puerto Rico. Just under half of those patients were either uninsured or covered by Medicaid. Close to half identified as people of color. In that same time, MetroHealth conducted more than 170,000 COVID tests and administered more than 120,000 COVID vaccines. And it was the only health system in Cleveland to require its employees to be vaccinated—months before a federal mandate was implemented.
The pandemic also inspired MetroHealth staff to accelerate the launch of a program long in the making: Hospital in the Home. For years, MetroHealth had planned to deliver monitoring and medical equipment to patients at home, with devices sophisticated enough to provide them with “hospital care” via a tablet computer. The service would include at-home devices that monitored heart rate, blood pressure, and blood oxygen levels—and automatically sent that information to doctors and nurses at MetroHealth who would use it to adjust their treatment during multiple virtual visits each day. With hospital beds filling during the pandemic, Hospital in the Home began delivering that care earlier than expected to MetroHealth patients sick enough to require all-day monitoring, but not sick enough to spend nights in the hospital. The program offered multiple benefits. Patients avoided the stress of a hospital visit, slept in their own beds, ate the foods they loved, and spent their days surrounded by family and friends. Their risk of hospital-acquired infections from other patients dropped to zero. As COVID cases rose and more hospital beds filled, staff tested and refined the new Hospital in the Home program. By January 2022, more than 900 patients had received MetroHealth hospital care at home.
“This,” Dr. Boutros said in the fall of 2021 at MetroHealth’s 2021 Annual Stakeholders Meeting, “is the future of healthcare—care we’ll soon be able to deliver throughout the state and, one day, across the country.”
