interviews
Managing The Unavoidable
by Michael Brumage
April 1, 2020
This interview with Michael Brumage, the Medical Director of Cabin Creek Health System and Program Director of Public Health/General Preventive Medicine Residency at WVU School of Public Health, was conducted and condensed by frank news.
frank: Thank you for speaking with us Michael. Will you tell us about your background?
Michael Brumage: My name is Michael Brumage, I'm an MD and I have a master's in public health. Currently I'm the medical director for Cabin Creek Health Systems. I'm also the program director for the general preventive medicine residency at West Virginia University in the school of public health.
I am a native West Virginian. I went to undergraduate and medical school at West Virginia University.
How did you get your start working on pandemics?
I started by working in internal medicine for the United States Army and later became a preventive medicine physician. From 2005 to 2007, I was the chief of preventive medicine at Tripler Army Medical Center in Honolulu. While I was in that job, I wore two other hats, one as the public health emergency officer, PHEO, for the Pacific Regional Medical Command, and PHEO for Joint Task Force-Homeland Defense, which covered all the U.S.-affiliated islands in the Pacific. I was up to my neck in pandemic planning.
At the time we were planning for Influenza A H5N1, the “bird flu”, the highly pathogenic avian influenza we worried would become the next pandemic virus. Fortunately, it never acquired the characteristics to spread easily from person to person. While it had a very high mortality rate, it didn’t spread easily. I understood what was at stake from the very beginning of this current pandemic.
This has transpired, largely as I hoped it would not.
How so?
I had hoped that our government would have been more proactive in seeing the danger and expressing that to the American people, and that did not happen. Now we have to make really hard decisions about what price we're going to pay. In places like New York City, Seattle, Boston, we are reaching the capacity of our healthcare system and may soon overrun it.
How will this affect rural communities, like yours in West Virginia?
We have to consider how we can prevent the spread to rural areas of the United States. Where we are in West Virginia, we serve people from all walks of life, but are primarily in underserved areas. We have clinics in formerly very heavy coal producing areas, and we deal with a lot of chronic illnesses like heart disease, lung diseases, and diabetes.
The Kaiser Family Foundation recently did a study evaluating at-risk populations for a pandemic.
West Virginia had 51% of its population over the age of 20 at risk for complications. The national average is 41%.
We are not only dealing with individual human beings that have chronic medical illnesses, but also Hepatitis B and C, and HIV cases related to intravenous drug use. In addition to these problems we now have to address a pandemic that strains our own internal capacity. What's most concerning to me is that we are working with very high-risk populations for complications from coronavirus.
How do you prepare for a pandemic in the face of that reality?
As the medical director, my effort in the last couple of weeks has been almost solely focused on preparing Cabin Creek Health Systems for a pandemic, which includes 11 sites in Kanawha County. We've been preparing to try to segregate people with respiratory symptoms away from other patients, moving toward deferring visits that do not require an in person visit, and trying to shift more to telephone and telemedicine to care for patients. We will still need to see patients in person for a variety of issues.
Yesterday I was in clinic for the first time in a while and actually swabbed someone for COVID-19. He had been on a cruise with two other family members with upper respiratory symptoms. I tested him for COVID-19 after donning personal protective equipment and administered the nasopharyngeal swab. We will find out the results in a few days.
This has been the pressing issue for me: worrying about a pandemic with the background of people in a state that ranks first in almost every bad category of health indicators, and usually bottom three for every good category of health outcomes.
It's a real challenge because our population is sicker than most.
If it hits here the way it does in other places, we're soon going to be out of ICU capacity and hospital bed capacity. There may be difficult triage decisions made for people to access care.
One advantage I think we have is that we are rural. People either live on ridge tops or they live in the hollows and that tends to create its own capability for social distancing. Whether you're in rural America or urban America, you're going to do pretty well if you practice social distancing. The question is whether or not we have the discipline to maintain social distancing, and biting the bullet on economic damage that it is going to do.
The case number is currently low in West Virginia. How are people responding in a place that is not visibly taken by the virus?
https://dhhr.wv.gov/COVID-19/Pages/default. | 39 Total Positive Cases as of 11:47PM PST 3.24.20
First of all, we don't really know how many cases there are. This is a huge blind spot everywhere in the United States, and here in West Virginia as well. While we know we have eight cases [on 3.21.20], I think everybody in public health understands that the real number of cases out there is much, much higher.
We are really like soldiers on a battlefield in a fog. We know the enemy is out there, but we don't know their strength in numbers.
I think many people here, from what I can gather from social media, are still in disbelief that this is as bad as it was because of messaging that came from some conservative media sources and the message that was coming from the White House for some time. I think the lingering effect of that is that there are many people who don't take it seriously. Two days ago, I went to a supermarket and I still saw people walking out with rolls of toilet paper under each arm, which I can't comprehend because there is no toilet paper shortage. And instead of just getting in and out with their toilet paper, I saw people congregating in the parking lot having discussions, which is an anathema to what we should be doing right at the moment.
Right. There is something strange about going to a store right now, without knowing what the future looks like – even with all the information I have, I pause and think, do I need more stuff?
Definitely. That attitude can be very contagious.
When we look to countries ahead of us chronologically, how can we use their experiences as a model?
If we stop and take a look around the world and how different people handled it, we're going to find success stories that could help lead us to a better place. One is China.
China of course, made the fatal flaw of suppressing the information on the virus, and we're all suffering because of it.
Because they have much more authority to enforce disciplined public health measures than we do in Western democracies, they were able to clamp down very rigidly on their population. This sort of radical social distancing and enforcement of quarantine seems to have worked in China. I think they may be out of the woods, depending on how they manage the subsequent waves of disease that are inevitably coming. While there may be no more new domestic cases, China is very connected to the rest of the world and can import cases.
Then you have South Korea. South Korea was an early leader in terms of number of cases and number of deaths. The Korean CDC is a capable and intelligent organization. They rapidly deployed testing kits and identified the people at risk and tested them. Whoever was positive, was isolated immediately. This is very widespread, population-based testing, an aggressive management of the disease seems to be flattening the curve in South Korea. They seem to be a model we can follow. In general, South Korea looks a lot more like Western countries politically, than they do a rigid, authoritarian country like the People’s Republic of China.
If we want to really get a hold of this, we have to expand testing radically.
Part of this is buying time everyday so we can slow the spread and allow industry to catch up, to allow research to catch up, and to implement widespread testing. This will really make a major difference in our response.
What can we expect given our current reality?
My concern is what frequently happens when you start to get success is that you become complacent. I anticipate we will eventually succeed in controlling this in some manner or another. The reality of the situation is going to hit home, even for the people who are still out there in denial. I anticipate that over the summer months, the disease will wane and give us the sense of security that we've kind of got this thing under control.
I really worry about what's going to happen in the fall if we let universities reconvene and schools reconvene.
People from all over the country are going to descend on campuses and share their viruses, which happens every year. This could reignite the whole situation. That’s why we really need to have a much tighter testing regimen in place by fall. We can buy time through the summer months and become very aggressive about developing testing, including point of care testing. There's a difference between what we're doing now with testing, which is the nasopharyngeal swabs and sending it off to a lab for evaluation, and things like the rapid flu test, which we can do in an office setting in about 30-45 minutes. We have a similar test already for influenza. In those cases we test, keep the patient in the office and tell them whether or not they have influenza. A similar test for coronavirus would be ideal. I believe it could be a prerequisite that the student body and the faculty would have to be tested and be certain they were negative before returning to campus.
Coronaviruses are not new to the United States. There are at least three other coronaviruses that show up in our communities and present like a common cold. What we are concerned about here is the more pathogenic and dangerous COVID-19 virus. We need a test that could be easily administered, and then we need to be able to isolate the positive cases that do come back away from the population.
In some ways, it's like when you think you've put out the forest fire, but those smoldering embers lying in wait can help reignite the fire all over again. My greater concern over the long term is that we become complacent and that this disease makes a resurgence in the fall months.
Data is finally emerging, but I feel like data is only as useful as the person interpreting it. How are you reading what comes out of China, Italy, or South Korea?
Data is also only as good as the people collecting it, and what they are collecting.
The Chinese data and the South Korean data especially, are the best gauges for what the real case fatality rate is.
There's a lot that comes into play here. So again, South Korea has done much broader testing, they're identifying the less symptomatic cases, as well as the extremely ill cases. The last time I looked, the fatality rate was 0.8%.
Italy on the other hand, is not doing the broad-based testing. It could be that their case fatality rate is in fact higher because they can't deliver the level of care required to every person coming in because they're making triage decisions – literally who's going to live and die. Because they are in this dire situation where they have outstripped their capacity, people who might have survived previously are no longer given that opportunity because there's not enough intensive care unit beds, ventilators, and intensive care unit staff. We have to look at all the data from a wide variety of angles.
What is the real number? I'm looking at the South Korean model as the most accurate, even though it's probably not perfect. If we can drive the case fatality rate down to 0.8% that means: a), we're doing enough testing and b), we're maintaining our capacity to care for those who are extremely ill.
What else do we need to pay attention to right now?
One is that we have to plan ahead for vaccine distribution. We know when this vaccine is finally produced, we are not going to have enough for everybody, and it's going to be available gradually as production increases. People like health care workers and first responders are going to be among the first in line. People at highest risk of disease are going to be next in line. We have to begin to communicate those priorities well in advance, in order to prevent public panic.
Think about people trying to get vaccine when you see people hoarding toilet paper.
The communication has to be clear.
One of the most touching things I saw in relation to pandemic preparedness was a mass vaccination on Saipan in the Commonwealth of the Northern Mariana Islands. In 2007 and 2008, the Department of Defense received an excess of flu vaccine they were planning on paying a company to destroy. At the same time there were people in places like the Pacific US territories that weren't getting enough. I thought, we have this need in the Western Pacific, so why not use it? I was able to get it shipped out and used as part of the community's pandemic planning.
How do we plan for a mass vaccination?
Ultimately, that's going to come down to planning at the local level. That means local health departments and hospitals and other health organizations will have to collaborate with law enforcement to set up mass vaccination sites that may include drive-through vaccination clinics where you are.
Got it.
I wanted to mention that at the end of this, we have to ask ourselves, “How could we let our public health system fail the way it did?”
When it comes to a pandemic, you see how the system has failed because it was underfunded and under-resourced at the federal, state, and local levels for many years. We often boast that we have the best healthcare system in the world. That myth is busted if we are failing even the doctors, nurses, and other staff on the front lines of this pandemic without adequate personal protective equipment. How could this be allowed to happen when we knew that a pandemic would eventually hit?
I was just listening to NPR on the way to talk to you and I heard somebody talking about how a pandemic bears a similarity to earthquakes, another periodic natural event. If you live in Los Angeles, you know that the big one is coming sooner or later. We knew pandemics were coming. It was inevitable. And yet we were so ill prepared for this.
This is a societal failing to undervalue public health.
We have to reimagine how we view health. We have typically viewed health through the lens of health care, when we know about factors called the social determinants of health that account for 80% of a population’s health. I'm talking about things like employment, economy, education, housing, transportation. All of these things play together in the health of people. The growing homeless problem you have in Los Angeles, in San Francisco, and even here in Charleston, West Virginia is a nationwide phenomenon, and these are people who are at high risk for all kinds of bad health outcomes. We are together only as healthy as the least healthy among us. They are the weak links in the chain of health. We have to have the view that we are interconnected.
We need to be prepared for the next pandemic that will inevitably come, and look at health from a holistic perspective. At the social services, at education. All of these things are crucial determinants of health for our nation and for our planet. If we fail to do that, then we have fundamentally failed to learn the lessons of this pandemic.
You’re so right about LA – it's cognitive dissonance. It's too big to wrap your head around. Right now there’s no looking away. Hopefully we use the opportunity as you suggest.
You nailed it. This cognitive dissonance is so true. We can't ignore it, and we're all paying the price for all of the weaknesses in our chain of health, in our chain of healthcare, and in our failure to plan for the inevitable. I think it's just such a profound quote from Tom Friedman who said, “We have to manage the unavoidable to avoid the unmanageable.”
And I thought, wow, that's really the whole pandemic in a nutshell. We have to face what's clearly in front of us. We can no longer look away, otherwise, we are setting up future generations for a failure on the scale that we see today.
interviews
Defining Terrorism
by Victor Asal
August 7, 2018
This interview was orignially conducted and published in frank on April 28, 2018.
This interview with Victor Asal, a professor and chair of public administration at Rockafeller College University of Albany, was conducted and condensed by frank news. It took place April 16, 2018.
My name is Victor Asal, I’m a professor of political science and Chair of Public Administartion at Rockafeller College at University of Albany, State University of New York.
I have three main areas of research. My first area of research is why people would go 400 miles out of their way to blow up people they’ve never met before. So criminal justice most times, most homicides are committed by people who know the other people. But going and killing people you’ve never met before, why would specific organizations do that? What are their strategies? That’s one area of research that I focus on.
My other area of research is why people are discriminated against by the State or by societies. Why are some people treated badly just because of the color of their skin, or their gender, or their sexual identity? I research all of those areas there.
These two areas of research are definitely connected.
My third area of research is the area of pedagogy in political science. What are effective ways of teaching students about political concepts, about the theories of politics? Specifically in the areas that I research. I’m a big fan of games, excerices, simulations — making a student a lab rat in their own experiment is much more useful than discussing why did Stalin do this? If I have an excersise where you are Stalin, and you did it, everyone else in class can ask you to explain it, it can be a different understanding.
Related to political violence I spent a great deal of time focusing on collecting new data that allows us to get traction under analysis on the organizational level, within a couple different contexts. The area of violent non-state actors. Why do certain organizations turn to violence? And when they do, why are some organizations much more lethal than other organizations? One of the things that I’ve found in my research is strong support for an argument that Ted Gurr made 47 years ago, about why men rebel.
There were a lot of people who disputed this and argued about this — but there's been growing literature that’s been focusing at the ethnic group level, that this is true, that this is one of the drivers of the use of political violence. I’ve been looking at this at the organizational level using a dataset called Minorities Risk Organizational Behavior dataset. And that’s ethnopolitical organizations in the Middle East and North Africa that claim to represent an ethnopolitical group, minority group. From the analysis, some of them are violent, some of them are not violent.
Can you tell me who some of them are?
Hammas, Amal, the PFLP (Popular Front for the Liberation of Palestine), lots of different organizations, again some are violent, some are not, and some go back and forth.
That makes sense.
The other data set, that really is the genesis of myself and colleague, Karl Rethemeyer here at U Albany, is the Big Allied and Dangerous data set, which has the acronym BAAD. The BAAD Dataset is the dataset of organizations that have already turned to violence, that are using violence, and to be able to look at why some of them are so much more lethal than others, or use CBRN weapons [chemical, biological, radiological, nuclear ] in terrorism and such.
One of the interesting things that we’re finding is that organizations that are networked tend to be much more lethal than organizations that are not networked.
What do you mean by networked?
Having allies. For example, how many things have you gotten by knowing somebody?
Nearly everything.
Right, so we’re finding that that’s true of organizations also. Organizations that have connections tend to be more lethal, tend to get a lot more done, in a lot of different ways. Friends can be very, very helpful.
The other thing that we’re finding is that organizations that are lethal tend to generate more rivals. There’s a cycle process. But there's another issue here, that really drives these organizations, and that’s ideology. There’s some really interesting theoretical and case study work by a guy named Mark Juergensmeyer. He talks about how ideology can compel organizations and people to kill. Because they have this power of othering…have you ever seen the movie Aliens?
No.
You should see the movie Aliens. It's a great movie. Our heroine, Ripley, she’s trying to protect this young girl from aliens. And the aliens are these sentient, intelligent creatures, that have this unpleasant habit of eating humans. Ripley stumbles into a nursery of baby aliens. I mentioned that the aliens are intelligent beings?
Yes.
If I can build an ideology that makes me the good guy, and makes you evil, or not really even human — that enables me to say I can kill as many of you as I want, and I can kill as many civilians as I want. So ideology, particularly religious ideology, has an important impact. And the combination of religious and ethnonaturalist ideology have a very, very important impact on the behavior of these organizations.
The issue of killing civilians gets at one of the core debates we are having about terrorism. Because the term terrorism can be used in many ways. And there are lots of people who use the term terrorism to describe any violent organization they don’t like. Those are the terrorists, these are the good guys. And if you’re trying to study this phenomena from an analytical, theoretical perspective, in my mind that is highly problematic. Because what that means is the definition of what we’re looking at is whether we like you or not. And that might be a great definition for seventh grade friendships, but not a great definition for doing analysis.
And there are big debates about what, and how we should capture terrorism, even if we’re talking about it in an analytical fashion.
How would you like to define it [terrorism]?
So I define terrorism not by if I like you or don’t like you. I define terroism by, are you a political organization, with a political motivation, who is blowing people up, and specifically targeting civilians?
Intentionally targeting civilians.
Yes. Intentionally targeting civilians, to hurt and kill civilians. Now, there are organizations that are insurgent organizations that target soldiers, there are organizations, terrorist organizations, that intentionally target civilians, and there are lots of organizations that do both.
It's one thing to shoot somebody in uniform, I don’t have to like it, especially if I’m wearing a uniform, but I would consider that very different behavior than blowing up a nursery school.
How do you feel about US military action, especially in the Middle East, where they are not fighting people in uniform?
When I say uniform I am using it prosaically — I’m saying fighters.
Any figher? Even if they happen to be a civilian?
If they are in a militia, they’re fighters.
Let me very clear here, there's another distinction about terrorism, when people talk about terrorism, mostly what they’re talking about is non-state actors. There is a whole discussion about State terrorism. In my mind, if the State is intentionally targeting civilians, they are involved in State terrorism. But again, that's a controversial topic as well. Which gets back to my other focus, which is political discrimination and political oppression. When it comes to violence, I primarily look at non-state actors. Both insurgents and terrorist organizations, and what factors are pushing towards targeting civilians and other kinds of behavior. But States can be pretty awful. And if we want to compare which kind of organizations, between non-state actors and States, which have killed the most amount of civilians, there is no contest. Russia did a phenomical job under Stalin slaughtering millions of people. Hitler. I mean, we could go on and on about States. There have been States that have been lax, and have killed civilians by being lax, and not paying attention. And there have been States that have intentionally targeted civilians, who they meant to kill.
Do you think your research can help inform policy or military action in dealing with these organizations?
I would hope so. One of the key aspects of the kind of data I’m collecting is that it can help you identify who to be most worried about. You should know that most terrorist organizations don’t kill anybody because they are fairly incompetent. And very few kill many people.
A really sad example of this is the invasion of Iraq. Where the U.S conquered Iraq and then fired the entire military, and put them out of jobs, and took them out of organizational structure, and that was a big mistake. Oppression in general is not a smart policy.
What are the fundamentals of understanding terrorism as you define it?
I think there’s normative components here, and empirical components. When it comes to thinking about terrorism,
Try to understand why these organizations are doing this, strategies to make them stop is important, and something we need to be paying attention to. And being able to draw a distinction between violent organizations, we may or may not not like their ideology, but they are not killing civilians. It's important to make the distinction between organizations that maybe you do like, that might be killing civilians. A concrete example is John Brown. His goal was to stop slavery. I am in favor of stopping slavery. John Brown slaughtered civilians. Intentionally. That makes him, in my mind, a terrorist, whether I like his ideology or not. Being able to make that distinction is important both analytically, but also normatively, for how we understand the world around us.