## Mary P Mercer: Beyond the marathon—notes from the relay of pandemic response

“We’ve been sprinting a marathon,” the email read. I sighed after reading it. It was the tenth time in as many days this analogy was used to discuss the pace of response to the covid-19 pandemic. It was mid-March, and along with other disaster service workers, I had been called to contribute to the public health response in San Francisco. We were working hard and watching with dread as more regions around the world experienced medical surge. Would our actions be enough to stave off the worst? I was feeling as sleep-deprived and stressed as I had been during intern year or early parenthood. And I was equally snippy.

“This is not a marathon,” I texted my friend, who had also recently become my boss in the Incident Command System (ICS). “A marathon is a singular race run by an individual,” I elaborated when we spoke. “Most people can’t run a marathon. But many can race 2-10 miles. This is more like a 200-mile, multi-person relay.” Recently, I have been reflecting on the relay analogy during many of my own daily runs. As we have transitioned into the second phase of response, with continued outbreak management and vaccine distribution on the horizon, many of the following relay principles will help to ensure our resilience.

The basic principle of a relay race relies on simple mathematics. By dividing the full distance of a race course into manageable segments, a group of people can travel that distance faster than any one individual could. The world record for a 4 x 400-metre race clocks in at just under three-minutes, whereas the single person record for 1600 meters is nearly a minute (or 25%) longer.

Disaster response is a long-distance relay. The ICS recognises this, and works to break time into manageable shifts, or operational periods. In response to a sudden disaster, such as a wildfire, where conditions change over the course of minutes and hours, operational periods in a command centre are often 12 or 24 hours, similar to those of frontline workers. In a pandemic, conditions change over the course of days to weeks, but the pace remains relentless. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential to double every few days. If unchecked, its exponential growth can easily overwhelm a health system and community. A team with sufficient depth is more likely to keep the pace necessary for a successful response.

Use principles of equity to support diverse runners through hazardous terrain

If your team is racing for more than a day, through different conditions, you must match the resources provided to the needs of each runner and the challenges each will face. This is what distinguishes equity from equality. For example, you would not have each runner carrying a flashlight and the same amount of water (equality). Instead, you might double the water ratio for the person running in the afternoon sun, and provide a headlamp and windbreaker for the runner crossing the misty bridge at midnight (equity).

Observations so far have shown that socially vulnerable communities (people who are elderly, or have mental illness, or are experiencing poverty and systemic racism) have also been most vulnerable to morbidity and mortality from covid-19. [1,2] In San Francisco, the Latin American community accounts for less than one fifth of the population but has experienced over 40% of diagnosed cases of covid-19. Our health system has tried to focus much of its efforts in response to bolster the availability of testing, treatment, and quarantine resources to those experiencing highest needethnic minority communities and people experiencing homelessness. Additionally, we know that in business and healthcare, diverse teams create better outcomes for companies and patients. [3,4] In our local response, diverse teams of community advocates, including Black African American, Latin American, and Chinese American community leaders and medical interpreters, have helped to promote evidenced-based testing and treatment with the cultural humility needed to foster trust in the response.

Use data to adjust the plan

Successful relay teams do not enter a race blind to their potential performance. They set a target pace for each runner. They track progress during training and on race-day to predict when handoffs will occur. In pandemic response, predictive modelling is used to plan for potential best and worst-case scenarios and to track how interventions are affecting response. Our data team has helped to assess the sufficiency of San Francisco’s ventilator cache, identify gaps in hospital bed capacity and develop staffing models for alternative care and quarantine sites.

Train with your team—especially on the handoffs

Relay teams spend a significant amount of time practising handoffs. Fumbling the baton in a 400-metre race can cost a team the lead. A principle of successful disaster response is frequent practice in responding to a variety of crises, with multidisciplinary representation. Whether through a “table-top” discussion of potential scenarios or a fully simulated exercise, practice helps team members become familiar with potential challenges and design solutions for their unique environments. Additionally, interdisciplinary drills help build relationships between organisations, as participants learn about the capabilities and needs of their partners. A shared understanding of problems can help response teams collaborate efficiently and smooth out transition periods across teams.

Rely on a strong support team

Finally, perhaps the most important components of a resilient relay and pandemic response are the support teams who bolster the efforts and morale of the runners and first responders. Most long-distance relays have two support vans. The “active van” supports those running or about to run. The ‘rest van’ supports those recovering from their most recent leg. At work, my active van includes colleagues who have helped graciously with scheduling changes and redefining responsibilities and deadlines. Even more important to my success, my rest van includes my family and friends, particularly my partner and children. While, many professions are documenting career setbacks faced by working parentsparticularly motherssuddenly faced with home-schooling, having dedicated support systems to share those responsibilities is an essential service for our essential workforce. [5] In the case of my support team, nourishment and rejuvenation have come in the form of excellent co-parenting, meals, bedtime stories, hand-drawn cards, text messages and Zoom calls. This generosity has helped me run my best race and prepare for the legs ahead.

Mary P. Mercer, emergency medicine physician, Department of Emergency Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center. She is currently serving as a Deputy Director of the Health Services Branch for San Francisco’s COVID-19 Response