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
Becoming Prosumers Of Energy
by Ruth Santiago
February 16, 2019
This interview with Ruth Santiago, a lawyer who works with community and environmental groups in southeastern Puerto Rico, was conducted and condensed by frank news.
How do you think of energy democracy?
Energy democracy stems from the effects of energy coloniality and how certain jurisdictions have been used for extractive and exploitative practices and have become sacrifice zones for operations that create great wealth for other people over time.
How did you get involved in this work?
I got involved because of proximity. We have this saying in one of the groups I work with that says, "The environment unites us and identifies us." Not just the subtropical dry forest, and mangrove forest, and salt flats, and offshore cays, but also things that impact that environment – they also unite us and define us.
I was raised to a certain extent in Salinas. I spent my formative, adolescent years here. I was born in the South Bronx, my parents were part of the return migration to Southeastern Puerto Rico. They were from a municipality that's a little bit further east of Salinas, but very similar in many ways in terms of being part of the sugarcane monoculture, a high concentration of Afro descendent people, and real situations of struggle and survival. They decided to return to Puerto Rico when I was 12. I was raised along this Southeastern coast on and off from that time. One of my memories of growing up here as an adolescent was the Aguirre Power Complex being built in the early 70s. It was something that came to us. We did not come to the nuisances. Nuisance was built where we are.
The government of Puerto Rico tried Operation Bootstrap. Rapid industrialization and a very intense industrialization program that affected Guayama with industry coming in. First, light manufacturing and then the petrochemical industry. Then, pharmaceuticals, which are still very present. These energy plants were meant to serve more than the communities. These big, central station, fossil fuel plants were meant to provide energy to those heavy industrial uses that consumed and required a lot of energy.
What we saw in two places in Southern Puerto Rico, one here in Salinas and the other over in Guayanilla in Southwestern Puerto Rico, was how the power plants were set up very close to the petrochemical industries. We had the Phillips Puerto Rico Core Petro Refinery. Aguirre Power Complex was basically in service to that and other heavy industrial users. People were told they would get jobs. They said, "Oh, we're going to generate upwards of 2,000 jobs." People were a little skeptical and concerned about how that would impact the possibility of safe fishing at least. They were told it would not be impacted. Ultimately, what happened was Phillips did not generate anything close to 2,000 jobs and folded after a few decades, but did leave a terrible legacy of contamination to air, water, and land. People lost a lot of their ability to do the subsistence fishing even.
Aguirre Power Complex came in stages. They had two power plants in one. In 1972, they set up what was known as the Thermoelectric Plant. Again, people were told they’d get jobs from this. Again, the plant does not hire many local residents. It’s estimated there was 20-25% local hires, and the rest came from all over, anywhere but Salinas and Guayama. The same thing with the Combined Cycle units, because as I said, it's two plants in one.
At the dawn of the 20th century Puerto Rico got its first coal-burning power plant and the only coal-burning power plant that was established by AES. They're a Delaware corporation with their headquarters in Arlington, Virginia, but they do business all over the world. In November 2002, they started a brand-new, so called clean-coal power plant. It's been disastrous. Again, people were told, this is going to be beneficial in terms of stimulating the local economy and bringing down the electric rates. None of that happened. What has happened is that people are getting more and more exposed to pollutants and heavy metals and public health is being impacted.
Your work seems two-fold. One is dedicated to producing energy that is actually clean and that will not leave a legacy of toxicity. The other is in trying to invert the power structure of how that energy is produced and sold. Correct?
Absolutely. Absolutely.
Can you talk about your work in both areas and how they come together?
We have done a lot of resistance work, and a lot of work to promote community alternatives on energy and sustainability issues. There's a long history of activism here. I became more active in energy issues around 2003. We started participating in the monitoring of the Aguirre Power Complex and how it impacts public health, air quality, and water. Both the sea water and the potable water. The only source of potable water here is the South Coast Aquifer. That was monitoring.
We started participating in different administrative proceedings with a group called Comite Dialogo Ambiental, the Environmental Dialogue Committee. Then we participated in proceedings against PREPA, the Puerto Rico Electric Power Authority, but also the AES Corporation.
I've done both administrative proceedings and litigation in courts related to different impacts from those plants, and most recently a company called Excelerate Energy out of Texas was proposing to build what they call an offshore gas port and a marine natural gas pipeline, that we just defeated. It would have been running right through the middle of Jobos Bay National Estuarine Research Reserve and impacted corals and seagrass beds and offshore cays and all kinds of things, and the ability of people to do subsistence fishing and ecotourism and otherwise just use and be in the environment.
We've done a huge amount of work with respect to the coal combustion residuals or coal ash waste related to the AES Power Plant. The coal ash waste is a concentration of heavy metals, toxic heavy metals that were being spread all over, and is now being accumulated at the AES Power Plant site in Guayama, Puerto Rico.
That summarizes the energy resistance work that we've done. In terms of going beyond resistance and seeking to build the solutions and the alternatives, we've done a lot of environmental education, both with Comite Dialogo Ambiental Inc. and another group, an umbrella organization called, Eco Development Initiative.
Prior to the hurricane in conjunction with IDEBAJO and a community board called Junta Comunitaria del Poblado Coqui, in Salinas, we helped start what is known as the Coqui Solar project. It's a community solar initiative. It was started with lots of workshops and consultation and collaboration with professors, like Efrain O’Neill from the University of Puerto Rico at Mayagüez, which is the technical campus here.
It was, for years, before the hurricane, quite a struggle to get people to understand, to want to move towards solar energy, especially rooftop solar communities. It was going very slow. We were certainly doing the education work and the policy work, but not getting very far on the ground in terms of actual implementation of the first steps, the pilot project for the solar community. But right after the hurricane when it became clear to, I think, everyone in Puerto Rico and probably anyone familiar with Puerto Rico that the current electric grid does not work for the people of Puerto Rico. People have been much more receptive to the Coqui Solar project and initiatives of solar communities and other alternatives to central station, fossil fuel generation.
Can you tell me how a solar community works?
That's something that's being developed right now. The way people in Coqui Solar envision it is people who have the appropriate rooftops, usually cement, which is not the case for everyone, are able to come together to think about and work on generating energy using PV systems on their rooftops. It's certainly much more than just everyone in the community having PV equipment. This is beyond just a technological solution. It's about the social agreements necessary to make that energy and that technology serve community needs in the most efficient way.
Are you seeing a lot of progress in new ways of approaching energy? From the community, but also from a municipal government level?
That's really hard to answer. Certainly with the mind set and attitudes. There's much more receptiveness to the things that we've been talking about for years about solar communities. That has definitely changed and there's a lot more interest and it's a very dynamic situation with respect to energy. After the hurricane, honestly, people realized we're basically on our own here and the government, local, federal, municipal, comes to help us. We have to figure out these solutions.
We're seeing a lot more on the formal scale. A group called ACONER, the Association of Renewable Energy Consultants and Contractors, say they're doing five to six times the number of installations they were prior to the hurricane.
Things have definitely changed. We don't know exactly how much.
There is what can be called, lip service. A lot of lip service about renewable energy which is dangerous, especially with the government of Puerto Rico. They're saying they're adopting the 100% renewable energy goal for 2050, and I think 50% by 2040, but their actions are promoting lots of natural and fracked gas. It's a tricky situation in that sense because you hear everyone saying we adopt renewable energy, but not only are they putting the money elsewhere, they're also talking about a kind of renewable energy that's not community-based,.
What we're seeing is that the government is being pushed by every energy company you can imagine. It seems everyone has an interest in doing some kind of project here, including at utility scale. That it is not the same as the kind of alternatives we're talking about in terms of solar communities.
Why is this an urgent issue for you right now?
We saw here in Puerto Rico, that it's a matter of life or death. People need to take this into their own hands, energy by and for the people. Become more than just passive consumers but actual producers of energy and control their means of production.
We knew before the hurricanes, and we experienced it afterwards. This huge and deadly hurricane was compounded by this terrible electric infrastructure system. It's not serving the people of Puerto Rico in a real way. Maybe that was the best we could do at some point, but that's no longer the situation here and we an opportunity to do things differently. To do better. Much better.