San Francisco Chronicle - (Sunday)
Doctor stirred COVID storm
Gandhi applied her HIV harm-reduction stance to pandemic, but approach aroused backlash in region stressing strict curbs
Up in her office on the fourth floor of San Francisco General Hospital’s Building 80, Dr. Monica Gandhi sat staring at an email she’d just received from the city’s health officer. One day earlier, on March 16, 2020, San Francisco and eight other Bay Area counties had ordered residents to shelter in place — and now this email was instructing her to essentially cancel all in-person appointments at Ward 86, the oldest HIV/AIDS clinic in the country, to curb the spread of a new pandemic.
While others were only beginning to imagine the future that lay before them, Gandhi, the ward’s medical director, was running through the downstream side effects of the guidance she’d just received. She thought about her patients without phones, without homes; the patients for whom the clinic was “the only touchstone of sanity in their lives … a place they felt safe.”
“I’m not saying anything crazy. I’m really not.”
Dr. Monica Gandhi, on her approach emphasizing human behavior to combat the coronavirus
This was the first time — but hardly the last — that Gandhi found herself questioning San Francisco’s conservative approach to the pandemic. She’d spend the next year and a half living in an uncomfortable gray space, advocating for a harmreduction approach to the COVID-19 pandemic that sometimes ran counter to a far more cautious approach held by many in San Francisco and other liberal enclaves. This would earn her fans and tens of thousands of followers on Twitter. It would also lead to some stinging backlash and a reputation as one of San Francisco’s most controversial infectious disease experts.
She got her first taste of that after sending her own email to staff at the clinic: “Recognizing that people living with HIV may have special needs and that over one-third of our patients are marginally housed, we will not be restricting in-person care for anyone at Ward 86 who is homeless and for patients the provider deems as needing in-person care.”
Not long after she pressed “send,” her phone rang. Hospital leadership was on the line. The message was clear and came with a rebuke: There would be no exception for Ward 86.
***
Gandhi, 52, is curled up, legs folded beneath her, playing with the hem of her dress. She’s warm and disarming. When her eyes meet yours, it feels like you’re the only person who has ever existed. She remembers the smallest details, re-creating graphical data from old studies in seconds.
Her office, two floors below Ward 86, feels like a second home. There are dozens of photos on the wall above her desk — of her two boys (11 and 13 years old); of her late husband, Dr. Rakesh Mishra, who died of cancer just months before the shutdown; of a small, tawny mutt named Frodo, who passed not long after. There are lamps and paintings and an illustration made (allegedly) from all the words of “The Great Gatsby.”
Everything about how she approaches medicine, she says, comes back to her practice as an HIV/AIDS doctor. That’s what drew Gandhi, who also serves as director of the UCSF Center for AIDS Research, to San Francisco in the first place. This was back in 1999 — the city’s response to the HIV/AIDS epidemic was already well regarded. At the outset of that pandemic, the response was fear, shame and abstinencebased messaging. Soon, though, city health officials recognized they needed to take a different approach, one that, as Gandhi puts it, made space for “the profound need of intimacy and the profound need of people to be together.”
The response was the development of a holistic, harmreduction approach to curbing the HIV/AIDS epidemic. This approach seeks to make room for human behavior in treating illness. It’s a method that understands, for instance, that simply telling people not to have sex works for only so long. Eventually they’ll stop listening to you. So, you meet them where they’re at. You offer them condoms or, more recently, preexposure prophylaxis in the form of a pill.
That philosophy has been successful in reducing new HIV/AIDS infections in the Bay Area, and Gandhi has taken this approach to heart.
It made sense to her, then, that she could apply the same thinking to the COVID-19 pandemic. At various points throughout the pandemic — during UCSF Grand Rounds, in media across the country (including The Chronicle) and, of course, on Twitter — Gandhi has pushed for students to return to the classroom, for nuanced guidance on safer holiday gatherings and for establishing metrics on when and how to relax certain safety measures, including masking.
Looking back, it all still feels like strong, evidence-based public health policy to Gandhi. And yet, plenty of people seem to disagree. As one of San Francisco’s loudest voices in favor of harm reduction, she’s received fierce backlash, and sometimes death threats, particularly on Twitter, where, for better or worse, much of the medical community has converged to discuss the pandemic response.
“I’m not saying anything crazy,” she says. She laughs a little. “I’m really not.”
***
In the weeks after the 2020 order to shelter in place, Gandhi kept a close eye on her patients. What she was seeing only confirmed her worst fears about closing Ward 86. “There was a lot of depression — depression, anxiety, substance abuse, overdose — the number of overdose deaths that we had, I can’t even name how many people we’ve had die in our clinic.”
Viral loads were on the rise, too — a cornerstone of HIV/ AIDS medicine is reducing a patient’s viral load, to get it as close to undetectable as possible. Now the pandemic was threatening years of progress. “I saw the (HIV) viral load suppression rate dropping in our clinic . ... That’s when I changed.”
By early June 2020, she was confident she could open the clinic safely. Other countries had proved masking, distance and ventilation were effective at reducing the spread of the coronavirus. It was clear to her the lack of inpatient care was more destructive than the risk of the novel coronavirus if proper measures were put in place.
Quietly, but in plain sight, she opened the ward with nurse manager Jon Oskarsson. He was immediately on board. “Monica’s a maverick, but ... none of this was an idea that she pulled out of thin air,” he says. “Every step of the way was evidence-informed.”
It will be years before the full impact of pandemic mitigation measures are understood, but to this day, she says there has been no known coronavirus transmission in the ward since it reopened.
Meanwhile, patient data supported Gandhi’s approach. She’s working on a paper now that shows reopening Ward 86 reversed the climbing viral rates among her patients.
Still, it would be months before Gandhi took her harmreduction approach to the public.
***
Shortly after the pandemic shut down much of the country, Twitter became a home for scientific discourse almost out of necessity, making social media celebrities out of dozens of scientists and doctors. At UCSF alone, there’s Robert Wachter, George Rutherford, Peter Chin-Hong and Gandhi, to name just a few.
“During 2020, there wasn’t the CDC sort of like being the arbiter of all the news, the evidence base … that was silenced during 2020,” says Chin-Hong, an infectious disease expert. “So what happened is that individual clinicians went onto Twitter to, really out of necessity, share information.”
Gandhi joined in April 2020 at the urging of a friend. In one of her first tweets, on May 3, 2020, Gandhi laid out what she saw as her role in the pandemic: “Our job as ID (infectious disease) doctors/public health is to protect vulnerable (people) from death; protect society from illness; protect public health.” She took the mission seriously in the months that followed, maybe at times obsessively, passing along her findings to an audience of nearly 70,000 on Twitter. She tweets and writes about T cells, about breakthrough infections, about masking — and about the concept of harm reduction.
Gandhi’s first brush with criticism came when she cowrote several studies about the benefits of masking and ventilation — both areas that fell squarely within her harmreduction approach. Most of the heat she got for that stance came from the right. Occasionally, too, she’d notice herself looking like an outlier when compared to other experts when interviewed on various topics. Was it safe for children to trick-ortreat for Halloween? Most experts said no. She said, Sure, no crowds and wear a mask.
But it wasn’t until this year, when she began to speak out about opening schools, that everything seemed to blow up. Her own children were back in class — she’d enrolled them in a private school while dealing with her husband’s illness — and it felt morally wrong that they should be able to learn in person while public schools remained closed.
She wrote about the topic for the Atlantic. Her argument was forceful — with vaccines rolling out, children should be allowed
to return to the classrooms; they’d suffered enough.
From there she went on to write several more pieces about schools and the equity of shelter-in-place mandates. All along, she watched the numbers, grounding her positions in data, and yet, the response could be intense — she’s been framed as attention-seeking, dangerous and anti-science. She still has trouble understanding why.
“To put it plainly,” she says, “I was never controversial. I went to Harvard Medical School, went to UCSF, just did everything right by all academic credentials, and I just thought why would there be any controversy about this approach? The approach that I took was that you shouldn’t close down everything, you should do things safely. …
“I just have never been attacked before.”
***
Gandhi’s parents left India together as a young couple in the late 1960s, looking to make a new home in Salt Lake City, where her father had been offered a job as an electrical engineering professor at the University of Utah. They had one child at the time, but they’d soon have two others, including Monica.
Growing up in Utah wasn’t always easy for her. Gandhi remembers how much she stood out, the only brown girl in a city so white in so many ways. She remembers the slurs the children shouted at her, too. She was a perpetual outsider.
Maybe this is where her empathy comes from, she says. Maybe it’s the trips to India, where she saw stark disparities in wealth. Or maybe, she says, it came from seeing a friend come out as gay in high school. “He got kicked out of his house,” she says, “and it was the middle of winter.”
Gandhi’s empathy comes up again and again with those who know her well. Her sister, Leena Gandhi, says that, as a child, Monica would cry for a wounded butterfly. “She cares a lot.”
All three Gandhi children became doctors. Monica found her place in that world by understanding how medicine might help those with less. “I think she was always very interested in the social aspects and the care aspects of medicine,” Leena says. “HIV care really afforded an opportunity because it was such — it’s close to primary care; you became an important part of your patient’s life.”
***
Ward 86 is on the sixth floor of an old brick building next to the renovated San Francisco General Hospital. On the outside, it looks like a place you might film a movie, all brick and arches and rusted green copper accents. Inside, it’s all linoleum and fluorescent lighting.
A social worker picks up the phone. “You have to get in here — we have to celebrate. Monica got here before 2 p.m.,” she says. Monica laughs. Her schedule is tight — in addition to managing the ward, doing research, mentoring students at UCSF, organizing conferences and raising two children, Gandhi has 80 patients of her own — so it’s not often she shows up early.
First up, a phone call to a patient who couldn’t make it to the clinic. Gandhi dials the number from memory and calls her “sweetie.” She listens to her talk about the pain in her arm, and then asks about how she’s dealing with the trauma from her stay in the hospital, many months earlier, because of COVID-19. “We love you,” Gandhi and the others say before they hang up.
The next appointment is harder. Gandhi welcomes a woman into the room and tells her she looks beautiful. The woman sits on a stiff, plastic chair opposite Gandhi and folds her hands in her lap.
“So I need to talk to you about something, I do not want you to worry, and everything is going to be fine,” Gandhi says. Then she delivers a stage one cancer diagnosis.
The woman begins to shake and sob. She felt like this was coming, she says. She pulls her mask down to get some air, and suddenly, Gandhi is on the floor, holding the patient’s knees and staring up into her eyes. Gandhi pulls down her own mask for a brief moment: “It’s very little, it’s very limited.” She says this again and again. “You’re going to be all right.” She wouldn’t lie, Gandhi says, not after what she’s been through with her husband.
“Do you trust me?” Gandhi asks.
“I trust you.”
***
On Nov. 29, 2019, weeks before COVID would become a fact of life, Dr. Rakesh Mishra, Gandhi’s husband, died. He’d been diagnosed with salivary gland cancer 10 years earlier. For an entire decade, Gandhi says, she and her husband lived in a space of “chronic uncertainty and fear of his death.”
Eventually, Gandhi says, she “managed to put aside the fear and the anxiety of what could happen, to actually live during that time.” There’s a piece of that lesson in her advocacy for harm reduction around COVID.
“When I see people so anxious, saying ‘I will go and live my life once COVID has truly been eliminated’ ... I feel sad because they are losing out on life, losing out on the joy, losing out on connections and losing out on things that they could have right now.”
That’s not to downplay the cost of the pandemic — she lost family members in India as the delta variant burned through the country. But Gandhi understands viruses. With vaccines and antivirals and the right safety measures, COVID is manageable, she says.
Gandhi has spent a lot of time thinking about why her messaging throughout the pandemic has received so much resistance — how a city that pioneered harm reduction during one pandemic could forget about it the next. Sometimes Gandhi wonders whether San Francisco isn’t the same city she moved to more than 20 years ago, whether the wealth and privilege here acts as a sort of blinder to the equity issues she believes her approach can help address.
Maybe it’s that the message is coming from her. “I’m a woman, I’m short, I’m of color, maybe that doesn’t have the authority — maybe it doesn’t give people as much confidence in our unconscious-bias society.” She doesn’t sound hurt when she says this — more like she’s guessing aloud.
But she’s not the only one who has noticed. Chin-Hong says he received a fair amount of criticism himself, but Gandhi, “she seems to get the lion’s share, the majority of it. … Is it gender, is it the topics she chooses, is it her views?”
There’s also something about social media discourse that seems almost incompatible with scientific discourse, he says. Earlier this summer, before the delta variant hit, Gandhi was confident that the worst had passed, that masks could come off. Chin-Hong and Wachter weren’t so sure; they saw what was happening in India as a sign of what was to come.
In the end, they were right and Gandhi was wrong, but, they say, they were always respectful of one another.
“There are some people I disagree with where I think they’re not paying attention to the science, they’re not reading it carefully,” Wachter says. “Monica is not like that at all . ... I often find myself shifting a little bit after listening to her.”
The public criticism, much of it on social media, is another thing entirely; it can be vicious and unforgiving.
“It weighs on me a lot — I’ve been feeling really uncomfortable in my own skin, in this city, for the last year and a half,” Gandhi says. “It’s really uncomfortable. I don’t know. Sometimes I’ve thought about leaving” San Francisco.
“I was never controversial. ... I just thought why would there be any controversy about this approach? ... I just have never been attacked before.”
Dr. Monica Gandhi
***
A few weeks ago, Gandhi tweeted that she’d be taking a break. Of course, she didn’t. Three hours later, she was tweeting again, this time about recent news that molnupiravir, an antiviral, had shown promise in reducing the likelihood of severe COVID infections. And that week, she published three additional essays in three media outlets.
When she’s asked about it, she lets out an exhausted laugh.
“I know,” she says. “There’s something about me — I can’t stop.”
As long as people are learning to live with COVID-19, she feels compelled to offer them her insight, whatever the response. Still, she’s ready for the pandemic to end. And she does see an end, or something like one, coming. With vaccines for children and new therapeutics around the corner, she imagines the virus will soon be endemic and manageable in the Bay Area.
When that comes, Gandhi says, she’ll thank Twitter, log off for good and go back to HIV/ AIDS full time. She’s already planned her final tweet.