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
Michael Casey on Blockchain and The Grid
by Michael Casey
February 20, 2019
This interview with Michael Casey was conducted and condensed by frank news.
Michael Casey is a writer and researcher in the fields of economics, finance, and digital-currency technology. He is a Senior Lecturer at the MIT Sloan School of Management and Senior Advisor for the Digital Currency Initiative at MIT's Media Lab, where he explores blockchain applications that advance financial inclusion, economic development, and resource efficiency.
We look to define terms as we enter new themes, incorporating blockchain and what it represents within energy democracy would be especially helpful.
To start, how do you define energy democracy?
There's a spectrum of things that would encompass it. The one we've been most focused on, in terms of how it impacts blockchain, is the idea of the ability of the user, and therefore the pro-sumer [the person who is consuming and producing power], to have the right to sell and buy at a market determined price. As it is now, utility is in the middle, purchasing power at a rate they predetermine. There's no capacity to sell to an alternative, other than a single provider.
A world in which I can enter into agreements that have my power purchased at a particular rate, whether that is literally delivering the electrons, or is a contract in which my provision to the grid is compensated at a rate that is determined by the demand for that particular quality of power, is something we're really focused on.
Which is the way the current structure is. You build onto that notions of broader democracy. The right to go off-grid, the right to establish your own systems for setting smart meters, for determining what devices are used and when. There's something of a spectrum in the concept, but the starting point we care about most is price, at least that I do.
What about ownership?
That would fall into it for sure. Yes, we definitely would put that into that same spectrum. The idea that the assets can be owned by an individual. There’s varying degrees to this. One is ownership and the other one is finance. The ability for me to finance the acquisition with whomever I can tap, rather than the electricity infrastructure I depend upon, being itself dependent upon the financing vehicles of utility. That I, or my community, can tap external sources to fund what is essentially our contribution to the broader infrastructure. You can get broader and broader with it, but the right to own and control those assets would be part of it. The right to determine how and who finances it is another part.
Where does blockchain come in?
I'll speak to it from the projects I've been specifically involved in. One is a microgrid we are experimenting with in Puerto Rico. I look at it in two ways. First is this concept of finance. I can tap my home or community and establish a microgrid. How might we have that financed by some sort of external direct investor, a social impact investor or investment fund? The blockchain creates the capacity to form what are known as smart contracts.
Are you aware of that term?
No.
Blockchain is a distributed ledger. It, in a decentralized manner, without any particular entity in charge, records the sequence of transactions and then, through a consensus mechanism, every node, every computer, within that network, each maintain their own version of the ledger, and update that ledger through this consensus process.
If you think about how we might move to a world where my transactions, my sale of power, my provision of power, and the funds I receive for those, are not being dictated by centralized utility – then the idea that we’re now no longer going to have one entity in charge of those transactions, and who gets to set those prices and who doesn't, starts to move us into this direction of decentralization.
We might, as a community, decide we're going to nominate some party to be in charge of the ledger, but again you're now trusting that entity to do so. Maybe the community appoints one household to run the ledger, and they're billing everybody, they're acting essentially as a local utility. You really haven't changed the model that much, you've just made it smaller, but it's okay. That could be a more efficient way to do things. Once you bring an outside investor in who says, "I want to make sure my collateral, some claim on that power, and the income that's generated, is being managed in a way that I can trust. I'm external to the community. Who am I going to trust to do that?"
A distributed ledger that nobody can change, gives me the capacity, potentially – I always use the word potentially, because all of this stuff is completely and utterly, in experimental phase right now – it gives us the potential to have my transactions verified without me having to trust the community member that is in charge.
You can imagine a situation where there's an investor in the United States, let's say in Seattle, who has put a five-year bond into the financing of a local community's grid in Africa. He's going to want to have some assurances that asset is being managed in a way that is in the interest to what they paid for. This is one principle idea to think about. Decentralization gives us the capacity, not just for those inside the community, but also outside, to have a relationship like this.
A smart contract is the idea that in addition to managing transactions, in the plain vanilla notion of what that is, payments of money, the actions that are taken by software to instruct devices to do things, or manage a set of contracts, can be executed without any one computer being in charge.
A smart contract is a bit of a misnomer. It implies that the contract is what's going on. The contract is an agreement between you and I. A smart contract says that you and I enter into an agreement and neither you nor I have any power over the computers executing the terms and obligations of that contract, to manipulate it.
How does this work in terms of smart property? I've got collateral, even though I'm living in Seattle and the microgrid I’m financing is in Nairobi. If payments are not met, it's a form of foreclosure or default protection. I funded this thing at a low interest rate because I'm protected. If the payments are not being made, at a certain point the system recognizes this because those payments are digital, they have programmable money qualities, and they stop. A device – a smart meter, one of the devices within the system, can divert that power back to the grid for example, so that the user is no longer using it. You can create a pay-per-use type of structure.
We thought long and hard about this from a social impact, developing world scenario. Could you build tiers into it so that certain devices always stay on because they have to? The hospital needs to have its power. Various things need to stay on, but you could then have some sort of structure in which the least necessary, or least important devices, can be turned off. And that power is diverted back to the grid until the loan is renewed and payments are revived.
You're creating a certain amount of de facto property rights that is the structure of so many other forms of lending. That's the way we think we can drive down the cost of lending. Rather than having to depend upon very centralized public finance models, in which infrastructure is built with access to Wall Street's funding, we now have the capacity, potentially, because I don't need to trust anybody in terms of the execution.
In that structure we can potentially bypass all of that, and have pools of social impact investors have direct stakes in, and help to fund the development of these smaller off-grid or on-grid types of microgrids. That's what we're working on in Puerto Rico right now. That access to finance. How do we create a sufficient level of protection? There's always the capacity that somebody could monkey with the smart meter. There's various things that could go wrong, but any investment has these factors.
The other part of it is, if you have a true transactive grid, it's not just a two way transaction with me and utility. I'm actually trading with my neighbors and setting up transactions and relationships. Then potentially the blockchain could be there as a way to tokenize the rights of that electricity. The transaction is between each of the participants in that network which itself would also be managed in a decentralized way. There's no utility. There's no large national or state level utility, nor is there even a local community utility. The utility in a sense, is the blockchain. There has to be built into it some sort of price mechanism. People are only going to enter into deals if you can potentially program devices, inverters and like, to accept or divert power over their prices, and meet whatever parameters you've set.
All that functionality, do I transact, do I not? Has the transaction been recorded? So there's no way I could do a deal with one person and actually divert the power somewhere else, and essentially double dip on the thing. All of that needs to be managed to keep the system in balance. That is where we see the second layer of a decentralized blockchain to come.
I feel at this stage, after a long time looking at all this, unconvinced that transactive systems like this are necessarily going to work. I do believe that in some shape or form, if you're going to reach this true energy democracy idea, something like this is where we need to go. But we're not there now. I think that's partly because we have these big, sensitive, national grid structures and it's not clear that the power loads and various sensitivities that go with how you keep the grid alive, and not kill people, can be managed entirely by this sort of structure.
This is just my thinking at the moment. It's not as if the broad principle of a more decentralized way to manage transactions between users and the grid isn't something we should be striving for. I am a believer in the finance part of it. Transactive systems, certainly in on-grid environments, are going to have to be capable of interacting with the demands of large service operators needs.
What about working on microgrids, or moving off the grid? Do you think that creates a better opportunity at moving towards decentralization?
Harvey [Micahel] is actually more of a visionary when it comes to the broader idea of energy democracy. A lot of his thinking has helped me on this sort of stuff.
There's certainly potential in off-grid settings.
Can we have a hybrid? Where you have an off-grid community based microgrid? It's not plugged into the national grid, except at such times when it needs it. So the national grid becomes the back up. That would be ideal. There's a huge political move. You'd need to get these utilities to really step back into a different role. While the grid is functioning in it's off-grid strategy, that is the microgrid, if you wanted to manage transactions within that community in a decentralized way, the blockchain could step in and be that management protocol for that system.
It seems like the private sector and academic institutions are the ones leading this thinking. Do you think the public and the political follow private sector investments?
That's a really good question. I think there are two barriers at arriving at this broad image of energy democracy. The first is that incumbents have a lot of power. Public utilities are heavily regulated. We find this in banking as well.
The regulators are told they must regulate the grid in such and such a way, and that is defined by default, under this current centralized paradigm. You have a lot of inertia from regulators who don't want to disrupt the model because you'd obviously have to design completely different regulations for a world in which these decentralized microgrids are built along the lines I just described. That's one barrier.
Then of course, the utilities themselves have their own political clout. If we want to depend upon their infrastructure, all that expensive capital that’s been invested into it, so that their wires are the ones we use to transact amongst each other, how are we going to compensate those utilities? There's an interesting question about how we might do so. It could be that they cease to be the providers of the power, or at least the sole providers of the power, and instead are just service managers and they take a service fee. One way to think about it might be to think about how the US telecoms industry was deregulated in the middle of the '90's. The baby bells were broken up and the like, there was a mandate that the pipes had to be provided to all comers, there would be a fee that would be paid, but there was no way you could prevent, as the owner of those cables, other providers from providing services along that infrastructure. That's one model that might be interesting when you think about it. But those guys, nonetheless, because the way their current profit models are built, and because of their political clout, are a barrier.
It’s probably at this stage, too marginal. There's not a big enough change in my savings or my profits as a pro-sumer, to really exist. It just hasn't got that "gee whiz", great motivator behind it. I think that's essentially the problem with lots of business models. It's just too incremental. How do you make this big shift if there are a lot of inconveniences involved? On the other hand, I think there is something wrong with that to some extent. We're not thinking hard about how, if we do decentralize, there's all these other business models and ideas that can be built on top of a more decentralized energy democracy system. Rather than thinking about the savings or profits, that I as a household pro-sumer may or may not make on my existing usage and sale of electricity, how do we incentivize bill systems? We now have all this information generated around price levels and the use of IOT devices, and we get more and more sophisticated, down to the device level – there is a way to actually build all these other services in the community. You treat the excess electricity that's produced as a way to then produce batteries. There's a way to fuel electric vehicles that run bus routes around the system, and those buses end up being almost like a back up battery component to the system. You end up running a much, much cheaper traffic system because there's a dual purpose here. You're the backup, you're the recipient of the excess power, and you're providing a service.
How does that get baked into a model that makes the provision of those services cheaper and regulated through this decentralized price signaling mechanism that is a combination of IOT and blockchain, that renewable decentralized energy systems could provide? I don't know what that looks like, but I can envision some very smart, econometric design systems that bring in smart IOT devices that turn on here, turn off there, and create a really rich pool of data around optimizing power, and where and when. There's a whole lot of benefits that could be derived, in a future model that we're not yet visiting, beyond the pros and cons of using it under our current structure.
The problem is people just can't think beyond their monthly power bill. To do that, you need communities to be really forward thinking and experimental in what they could build in the future.
Utility is massive and ubiquitous, but still weirdly opaque, which leaves most people confused. I never think about my utilities bill. Where does trust come into play? Especially with blockchain. Does the public have a distrust in blockchain?
If designed appropriately, and if we reach the point where software and the models and protocalls that are being developed and constantly refined and proved, are trusted to the extent they should be, then they're actually a trust replacement system. That's exactly what they're supposed to be.
When I was talking about how a social impact investor in Seattle can feel confident that their interests are being protected in a smart property financing structure with a microgrid somewhere else, the question of trust is key. I can't trust the local village chief to act in my interest. We just cannot. We have all these barriers to trust around our economy built on those things. Just as there's no reason why the villagers should trust that if I had control over the devices, I wouldn't manipulate and divert the power to my own interests.
It is precisely the problem of trust you're trying to resolve through a blockchain solution. But you asked the right question because we're not yet there in terms of the public perception of blockchain. I personally feel there's a host of misplaced narratives and a deep level of misunderstanding. Some of which is promoted by vested interests who don't understand what's going on.
There's also a lot of really shady, funky people working in this space that have done some bad things. And they've been able to do bad things because the technology itself isn't advanced enough to be able to give the right level of protection. The good news is there is a lot of work being done on security and improving the system so that we're going to reach this level where a) the confidence that people can have that they won't loose their phones is higher and b) they can do so in a way that they don't actually have to trust a custodian. Because right now in a blockchain, bitcoin type solution, the broader ecosystem around it is still being serviced by entities who have control over your money. It's a bit of a hybrid that's not necessarily reliable.
Systems that have a more decentralized, but also highly reliable security model are coming, and that is going to hopefully bring people around to start placing better confidence and trust in the system itself.
If you just look at the way Puerto Rico’s public utility was run, and the abuse, it's hard to say I should trust that. Wait until you see PREPA and what's happened there. There's no trust in the system. One of the reasons why I think Puerto Rico looks like a really good opportunity for us to explore this is because there's such a breakdown of trust in the publicly run system. They're looking for alternatives and we're able to dive in and explore ways we can make it fairer for everybody.